Normile, Jane 1 1)G
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name F ane MiddM NormLast ile S Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/30/2016 72 years War or Dates
14 Place of Death Hospital, Institution or
Z City,XIVA XXXNEX3e Schenectady Street Address Ellis Hospital
W
Manner of Death„❑Natural Cause El Accident ID Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
tij Medical Certifier Name Title
c Cathy Sims-o'neil D 0
l'i'OtieRlsott St, Schenectady, N Y 12308
Death Certificate Filed District Number Register Number
City,xi MAItibe Schenectady 4601 105
El Burial Date Cemetery or Crematory
02/04/2016 Pineview Cemetery
0 Entombment Add ess
['Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
2❑and/or Address
Cl)
Hold
0 Date Point of
t ❑Transportation Shipment
Et by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Densmore Funeral Home Registration Number
Name of Funeral Home
Addcie Sherman Ave., Corinth, N.Y.
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z Address
1r
W
Permission is hereby granted to dispose of the human rem d cribe•ft ve . indicated.
Date Issued 02/01/2016 Registrar of Vital Statistics
(signature)
District NumbeI601 Place Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ILI Date of Disposition -./'I i C Place of Disposition p,hc, V; G rC.V'^U; f y
2 (address)
tAl
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 3Gr r^Zy S El.A Ce,S
(please print)
iLi. Signature / —. ,r Title C fP)ry ifc(
(over)
DOH-1555 (02/2004)