Banning, June , %, ti VV/
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
June I Banning Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/13/2015 83 years War or Dates
.1 Place of Death Hospital, Institution or
City, Town 4X Saratoga Springs Street Address Marys Haven
a Manner of Death LA,Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
to Medical Certifier Name Title
G Rodney Ying MD
Address
59 Myrtle Street Saratoga Springs, Ny
Death Certificate Filed District Number Register Number
City, ToXvjeX'4(!k XX Saratoga Springs 4501 198
❑Burial Date Cemetery or Crematory
❑Entombment 04/14/2015 Pineview Crematorium
niiAddress
iii EICremation Queensbury N Y
Date Place Removed
Z Removal and/or Held
Q❑and/or
� Address
to
Hold
0 Date Point of
gi El Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
kiii Name of Funeral Firm Making Disposition or to Whom
}- Remains are Shipped, If Other than Above
Address
tr
Permission is hereby granted to dispose of the human remains ribed above as indicated.
Date Issued 04/14/2015 Registrar of Vital Statistics 0—QM 19. -4-EitAn4
(signature)
District Number 4501 Place Saratoga Springs
:,i:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Tigil,
tl Date of Disposition 4p ls@ is' Place of Dispositionr<, {0,,,„
(address)
Ili
CA CC (section) d (dot number) (grave number)
Name of Sexton or Person in Charge of Premises ,A
(please print)
,.,:•::...: Signature �'"' f Title ' "'f` 3
(over)
DOH-1555 (02/2004)