Jensen, Floyd NEW YORK STATE DEPARTMENT OF HEALTH 01 g5
Vital Records Section Burial - Transit'Permi t
Name First Middle Last Sex
Floyd William Jensen Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 3, 2012 91 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death I XI Natural Cause I I Accident I I Homicide Suicide Undetermined Pending
O. Circumstances Investigation
tft Medical Certifier Name Title
0 Sean Bain MD
Address
100 Park Street,Glens Falls,NY 12801
• Death Certificate Filed District Number Regist rmber
• City, Town or Village Glens Falls 5601 j
❑Burial Date Cemetery or Crematory
❑Entombment April 5, 2012 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
O and/or Address
H Hold
CO
O Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1I Remains are Shipped, If Other than Above
2 Address
lY
ILI
Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued /51/2 Registrar of Vital Statistics W W
"Ars%igteTwo
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed� of in accordance with this permit on:
Z Place of Disposition 1' U C •W Date of Disposition A �, I.�1v�L p es �w r�*-� nN.._
W \ (address)
N
CC (section) (lot�mber) (grave number)
QName of Sexton or Person in Charge of Premises /4ny -c.- 0(A..b►-
Z (please print)
W A)Signature � Title Crt►olor dt.
(over)
DOH-1555(02/2004)