Pennock, Kathleen ,
9
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
vg
Kathleen D. Pennock Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 24, 2016 100 War or Dates
.. Place of Death Hospital, Institution or
;fig{ City, Town or Village Queensbury Street Address 6 Lewis Road
'm: Manner of Death X Natural Cause ❑Accident ❑Homicide ❑Suicide n Undetermined n Pending
Circumstances Investigation
sJ Medical Certifier Name Title
.. Joseph C.Minhindu Dr.
Address
20 Murra Street Glens Falls NY 12801
e. Death Certificate Filed District Number Fe i1s tr4Number
4 City, Town or Village Queensbury 5657
❑Burial Date Cemetery or Crematory
December 30, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
oand/or Address
Hold
U)
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
pi Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
. Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human e ins described novas ihdicated.
Date Issued I c )cl(pRegistrar of Vital Statistics t
(signature)
f
e,, District Number 5657 Place Queensbury
F
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILJ Date of Disposition /Zf3d//0 Place of Disposition i.)1e-(�)i 6IC� T
W ! (address)
CO
Z (section) lot number) (grave number)
00 Name of Sexton or erso in Charge of Premises & /ioyi a-4 c c- c P
Z (pleaseprint)
W /
Signature Title G-re, y D r I Ec-L1, -
l� (over)
DOH-1555(02/2004)