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Penders, Barbara 41 )3 NEW YORK STATE DEPARTMENT OF HEALTH 4"1 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Barbara Sullivan Penders Female Date of Death Age If Veteran of U.S. Armed Forces, ,,,,, November 28,2014 72 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address 7 Wallace Drive Medical Certifier Manner of Death I�I Natural Cause n Accident n Homicide Suicide Undetermined U Pending Circumstances Investigation Name Title Paul Filion,MD Address -'` Glens Falls,NY ,v, Death Certificate Filed District Number Register Number i , City, Town or Village Glens Falls,NY 5601 5`" ❑Burial Date Cemetery or Crematory December 1,2014 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed ZZ n Removal and/or Held and/or Address E Hold 0 Date Point of n Transportation Shipment p by Common Destination Carrier n Disinterment Date Cemetery Address 1-1 Reinterment Date Cemetery Address Permit Issued to Registration Number f Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address { 407 Bay Road,Queensbury, NY 12804 f Name of Funeral Firm Making Disposition or to Whom ;.< Remains are Shipped, If Other than Above Address } a,,.:,‘4 Permission is hereby granted to dispose of the human remains de /"b ,ve $ dicated. ' i �Date Issued ///Z/Zc>1 y Registrar of Vital Statistics (signature) 0 District Number 5601 Place Glens Falls,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition (1.(t l rk( Place of Disposition gli . (,.w;-/p,..... W (address) Cl) cc (section) /Ir (lot nu ) (grave number) Z Name of Sexton or Person in Charge of Premises A.,* ° '' Please print) W Signature Gjj Title CIll (over) DOH-1555(02/2004)