Ensor, Jean LgNEW YORK STATE DEPARTMENT OF HEALTH s 1 gVital Records Section Burial - Trsit Permit
Name First Middle Last Sex
Jean Margaret Ensor Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/13/2016 91 War or Dates
I- Place of Death Hospital, Institution
Z City,Town or Village City of Albany or Street Address Albany Medical Center
Q Manner of Death Natural Accident Homicide ❑ Undetermined ❑ Pending
W Cause ❑ ❑ ❑ Suicide Circumstances Investigation
W Medical Certifier Name Title
p Kiron Nair MD
Address
43 New Scotland Avenue Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1221
Date Cemetery or Crematory
❑ Burial 06/14/2016 Pineview Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
N Hold
Date Point of
a, Transportation Shipment
Cl)_, ❑ By Common
0`; Carrier Destination
El Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 14015
Address
407 Bay Rd. Queensbury, NY 128/04
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
Address
U°
�-; Permission is hereby granted to dispose of the human remains descr d above as indi a d.
Date 06/13/2016 r�Issued Registrar of Vital Statistics L(signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
li Date of Disposition �(!SII&b Place of Disposition 'NV� ( .--
W (address)
luth
W (section) (lot number) (grave number)
0
w Name of Sexton or Person in Charge of Premises cr S"ter
(please print)
Signature el Title C t
(over)
DOH-1555 (02/2004)