Heinzelman, Linda NEW YORE STAPE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
': Name First Middle Last Sex
Linda P. Heinzelman Female
Date of Death Age If Veteran of U.S. Armed Forces,
=a August 29, 2012 58 War or Dates
Z. Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 27 Willow Road
ci Manner of Death Natural Cause n Accident n Homicide n Suicide Undetermined Pending
W. Circumstances Investigation
Z Medical Certifier Name Title
Address
= ` Death Certificate Filed 3 District Number Register Nu ber
4 City, Town or Village Queensbury 5657 /06
®Burial Date Cemetery or Crematory
❑Entombment September 1, 2012 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
Z I l Removal and/or Held
and/or Address
H Hold
a
O Date Point of
N n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
s, Permit Issued to Registration Number
' Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
_ 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
+a Remains are Shipped, If Other than Above
S. Address
tit
fki
Permission is hereby granted to dispose of the human refriains described above . 'ndicated.
Date Issued _8-3)- o i, Registrar of Vital Statistics ty --
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Lu Date of Disposition 9/1 /1 2 Place of Disposition Pine View Cemetery
W (address)
ui Erie 78 C 2
tY
(section) (lot number) (grave number)
p Name of Sexton or Person i Charge of Premises Michael Genier
Z (please print)
W Signature ' ,+-. Title Superintendent
(over)
DOH-1555(02/2004)