Hein, Marjorie NEW YORK STATE DEPARTMENT OF HEALTH (, S
Vital Records Section Burial - Transit
{ Name First Middle Last Sex
r Marjorie F. Hein Female
0 Date of Death Age If Veteran of U.S. Armed Forces,
le July 15,2015 91 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Town Of Queensbury Street Address The Stanton Nursing&Rehab Center
Manner of Death n Natural Cause n Accident n Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Kenneth France MD
ft
Address
152 Sherman Ave.Queensbury,NY 12804
Death Certificate Filed District Number Register� Number
City, Town or Village Queensbury 5657 .<"--
❑Burial Date Cemetery or Crematory
❑Entombment July 17, 2015 Pine View Crematorium
Address
0 Cremation Quaker Road, Queensbury, NY 12804 _
Date Place Removed
zO n Removal and/or Held
and/or Address
,I-- Hold
CO
0 Date Point of
N Li Transportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
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Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
g:; Address
407 Bay Road, Queensbury, NY 12804
/04 Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains de cribed bove as indicated.
Date Issued a istrar of Vital Statistics
(signature)
(7- District Numbe€cpc"1 Place 0 LQ___,r.\ O.�
Ut..JZ-32-6
I certify that the remains of the decedent identified above were disposed of in a orda e with this permit on:
Ili Date of Disposition '1/Za f h( Place of Disposition ZiL' a,.t4,r*,,r
W (address)
CO
Ct (section)
// (lot number) C' (grave number)
Z Name of Sexton or Person in Charge of Premises iA , .,3E6,
.44
W ( ease print)
Signature i . Title lilt ctfbtL
(over)
DOH-1555(02/2004)