Miner, Denise N. # zso
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
•a Name First Middle Last Sex
ix.: Denise H. Miner Female
r.•
Date of Death Age If Veteran of U.S. Armed Forces,
:' April 10,2014 58 War or Dates
4 Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 383 Corinth Road
1Manner of Death X Natural Cause ( (Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
:piAgeel Gillani Dr.
Address
:•:r 102 Park Street,Glens Falls,NY 12801
'r.•. Death Certificate Filed District Number a is r Number
;rrss City, Town or Village Queensbury 5657
El Burial Date Cemetery or Crematory
April 14, 2014 Pine View Crematorium
❑Entombment Address
Ex Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
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0 Date Point of
N ( (Transportation Shipment
a by Common Destination
Carrier
( I Disinterment Date Cemetery Address
( (Reinterment Date Cemetery Address
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pr° Permit Issued to Registration Number
°;›: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
f?? Address
407 Bay Road, Queensbury, NY 12804
:-74° Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
°' 7:? Permission is ereb granted to dispose of the human remains describedlabove as indicated.
Date Issued ) fRegistrar of Vital Statistics K�_Q R-t1�
;:*: (signature)
??? District Number 5657 Place Queensbury
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition if Illoliti Place of Disposition TinithteJ ►'0 7 a...
(address)
W`
N
X (section) �(lot number) (grave number)
pName of Sexton or Person in Charge f Premises i 7 .34 4
Z dri.s—
Signature (plea a print)
w Title et,04, z
(over) j
DOH-1555(02/2004)