Vincent, Bonnie NEW YORK STATE DEPARTMENT OF HEALTH 4- 13 .
Vital Records Section Burial - Transit Permit
lii Name First Middle Last Sex
Ronnie D. Vincent Female
Date of Death Age If Veteran of U.S. Armed Forces,
1iiiiiiiii ` 03/14/2011 54 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Town of Hadley Street Address 12 Riverview Drive
8Manner of Death Natural Cause 0 Accident 0 Homicide Suicide 0 Undetermined Pending
#f1 - Circumstances Investigation
hi Medical Certifier Name Title
4 David Mastriani MD
lic
Address
3 Care Lane, •Saratoga Sp. , NY 12866
Death Certificate Filed District Number Register Number
Mi City, Town or Village Town of Hadley zi-SSg
Date Cemetery or Crematory
0 Burial 03/1 5/7011 Pineview Crematory
Address
Cremation Quaensbury, NY
Date Place Removed
0 0 Removal and/or Held
•— and/or Address
Hold
O Date Point of
N0 Transportation Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
0 Reinterment Date • Cemetery Address
Permit Issued to Registration Number
'>' Name of Funeral Home Densmore Funeral Home, Inc. 00442
s Address
7 Slier man Ave Corinth, NY 12822
,,...: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
I§"' Address
w
f
Permission is hereby granted to dispose of the human rer5ins described above as; dicated.
iiili Date Issued 3/1' 5 41.11 Registrar of Vital Statistics L,--6 a 6' _Aii
(signature) -
iiiili': District Number`i 55 )( Place Town of Hadley, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iI /�Wf; Pm:
Date of Disposition 3`•t(-II Place of Disposition Uity C. ctd
orti4...-
2 (address)
iG!
0
CC (section) A ,, ii(lot numb9�'• (grave number)
O l Name of Sexton or Pg on in Charge Premises t%s �t�+rt*
g (please print) p
> Signature L ✓� k Title CO A Mti 0`
(over)
DOH-1555 (9/98)