Hennessey, Adeline / 7711
`f
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Tr rl r
Vital Records Section a $ Permit
it
Name First Middle Last Sex
Adeline V. Hennessey Female
K. Date of Death Age If Veteran of U.S. Armed Forces,
it: December 28, 2016 96 War or Dates NA
Place of Death Hospital, Institution or
City, Town or Village Town Of Granville Street Address The Orchard Nursing Centre, Inc.
ii
c Manner of Death N1 Natural Cause n Accident n Homicide pi Suicide n Undetermined n Pending
Circumstances Investigation
r Medical Certifier Name ,it��f l Title Ai
Address
ll)�Z/ , /- qq oz r4//// ,4-y.
ttl Death Certificate Filed District Number Register Number
4 City, Town or Village Town of Granville,NY 575-6 S 3
❑Burial Date Cemetery or Crematory
❑Entombment December 3, 2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
Hold
CO
Q Date Point of
A. ❑Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
ifi 53 Quaker Road, Queensbury,NY 12804
`' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
.
ry Address
above as indicated.
Permission is hereby granted to dispose of the human remains described
} %�'� Date Issued 1 30/1(, Registrar of Vital Statistics 4 (signature)
District Number S7S6 Place 7wnt 0 F 6(1/;-11/4)0LLS , )'i1 Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z U C�ire,..-
ui Date of Disposition It(3) lib Place of Disposition of fr�
W (address)
(l)
QCL (section) (lotnum r) (grave number)
Name of Sexton or Person in Charge of remises hr•jip )t.,.l(d-
�Z (d/ease print)
Signature a 17
Title (P�fl»t1 '(t
(over)
DOH-1555(02/2004)