Dennett, Donna it ES.?
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
.' Donna Marie Dennett Female
IN Date of Death Age If Veteran of U.S. Armed Forces,
, 7/4/2018 79 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 20 Jay Road West
Manner of Death C Natural Cause i l Accident n Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
p Dr Borgos,MD
Address
Queensbury,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657 93
❑Burial Date Cemetery or Crematory
❑Entombment July 9,2018 Pine View Crematorium
Address
i Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
H Hold
M
O Date Point of
CL y ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
'< Permit Issued to Registration Number
�tt
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
AF Address
kCk 53 Quaker Road,Queensbury,NY 12804
sxZ
Name of Funeral Firm Making Disposition or to Whom
rOm
Remains are Shipped, If Other than Above
Address
17,4
iril
Permission is hereby granted to dispose of the human remains described above as indicated.
t Date Issued 1 'LP- 2.0 12 Registrar of Vital Statistics -47,411-it- -1A-As)E. Q.e.A
t; (signature)
K District Number 5657 Place Town of Queensbury,NY
▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition 'ill I IIt Place of Disposition P,..,U,`,,, i a.----
W (address)
CO
X (section) Alot number)( (grave number)
cl Name of Sexton or Person in Charge of Pr mises a,i g.AP,l'C)
'Z ,fir (pt ese print)
Signature fly+ 1-- Title cif 'tjOKi
(over)
DOH-1555(02/2004)