Mornhinweg, Reita # 5101
NEW YORK STATE DEPARTMENT OF HEALTH �
Vital Records Section Burial - Transit Permit
.:: Name First Middle Last Sex
ti:r Reita Mornhinweg Female
•:
Date of Death Age If Veteran of U.S. Armed Forces,
September 8, 2014 79 War or Dates
IPlace of Death Hospital, Institution or
City, Town or Village Ft. Edward Street Address Fort Hudson Nursing Home
i3 Manner of Death X Natural Cause i 1 Accident Homicide Suicide Undetermined Pending
tsgl Circumstances Investigation
la Medical Certifier Name Title
gi Eileen Spinelli MD
j Address
9 Carey Rd,Queensbury,NY 12804
:;:.) Death Certificate Filed District Number Register Number
,::::.: City, Town or Village Fort Edward 5755 5 6
f ❑Burial Date Cemetery or Crematory
September 9, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F_ Hold
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
: :.: 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
Remains are Shipped, If Other than Above
Address
Ai
Permission is re y granted to dispose of the human re ins described a ove a indicated.
Date Issued (4 Registrar of Vital Statistics V ' V� 0
(signature)
. District Number 5755 Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 4iiJil Place of Disposition ,n+.�f,,,� Lrcr,elvr....
Ili
(address)
U)
0 (section) /f (lot number)., (grave number)
pName of Sexton or Person in Charge of Premises X,.r o. ,10,4�
Z (/lease print)
W Signature At . - Title C 1K AnIrtt.
(over)
DOH-1555(02/2004)