Doheny, H A- i it/6---)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
H. Winona Doheny Female
Date of Death Age 1 If Veteran of U.S. Armed Forces,
9/15/2018 88 War or Dates n/a
Place of Death Hospital, Institution or
Z City, Town or Village Ballston Spa Street Address 26 Rock Rose Way
pManner of Death X Natural Cause n Accident —Homicide Suicide n Undetermined Pending
WCircumstances Investigation
W Medical Certifier Name Title
C Jennifer Stratton,MD
Address
Queensbury,NY
Death Certificate Filed District Number Register Number
City, Town or Village Malta,NY ` k7bO (4Lk•
❑Burial Date Cemetery or Crematory
September 19, 2018 Pine View Crematorium
❑Entombment Address
Ni Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N —
0 Date Point of
O. LI Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
2 Address
IX
W
0. Permission is hereby granted to dispose of the human rema' s des`ribed ve s i 'cated.
Date Issued ‘8,S0-.20tt Registrar of Vital Statistics
(signature)
District Number (.4 SIG Place -----Co. ,4-‘ 0 c. Mc,% -cam
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Lu [r
Date of Disposition 1 III Ilq Place of Disposition ?it
(address)
W
Cl)
0 (section) 71 lot number (grave number)
pName of Sexton or Person in Charge of Premises r,i L PAW
Z (please print)
W
Signature Title 1 17/2
(over)
DOH-1555(02/2004)