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Henry, Marie 1 y+.' f 4 Fr (l t NEW YORK STATE DEPARTMENT OF 1EALTH Vital Records Section Burial - Transit Permit in Name First Middle Last Sex Marie L . Henry Female M. Date of Death Age If Veteran of U.S. Armed Forces, 03/02/2011 75 War or Dates n/a .Place of Death Hospital, Institution or Kingsbury , NY Deer Run Dr . City, Town or Village Street Address Manner of Death Lu1771Natural Cause 0 Accident 0 Homicide 0 Suicide ElUndetermined 0 Pending W. Circumstances Investigation W Medical Certifier Name Title Steven Craig Coroner Address 470 Hadlock Pd . Rd . Fort Ann, NY in Death Certificate Filed District Number Register Number City, Town or Village 03/04/2011 .- 4o3 dii❑Burial Date Cemetery or Crematory 3/7/2011 Pine View Crematory. mi❑Entombment Address ;: ;Cremation Quaker Rd . Oueensbury , NY Date Place Removed Z❑Removal and/or Held and/or Address t Hold to O Date Point of Transportation Shipment ❑ a by Common Destination Carrier ❑Disinterment Date Cemetery Address ii Reinterment Date Cemetery Address Permit Issued to Re ssrrto4n Number Name of Funeral Home Regan and Denny Funeral Home Address Queensbury , NY • ; : Name of Funeral Firm Making Disposition or to Whom }► Remains are Shipped, If Other than Above • Address 2 fl` Permission is hereby granted to dispose of the human remains described above as indicated. iiM Date Issued 2- `/- b?© // Registrar of Vital Statistics `k, /Y1a41,... (signature) '' District Number 6'71. - Place ,V-1.070 y 4. / t hi I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 W Date of Disposition 1-1-x( Place of Disposition Pi4A ULeJ (_I14«f oew,ti 2 (address) In Ul E (section) (ilif‘stfks..- ) (lot numb (grave number) Name of Sexton or Pers nin Charge of emises (pleaseprint) vi/w it- 2 • Signature / A6 Title CROM 0� 9 (over) DOH-1555 (02/2004)