Hoerning, Ilene NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ilene W. Hoerning Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 15, 2014 93 War or Dates
i.. Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 11 Ashley Place
`p Manner of Death 0 Natural Cause n Accident 0 Homicide Suicide Undetermined 1-1 Pending
Circumstances Investigation
ui Medical Certifier Name Title
David Cunningham Dr.
Address
3 Irongate Center,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 s
❑Burial Date Cemetery or Crematory
❑Entombment January 17,2014 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z 0 Removal and/or Held
and/or Address
H Hold
Cl)
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 Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2 Address
CL
a.
Permission is herebr granted to dispose of the human re ' s described abov�' indicated.
Date Issued I e `� Registrar of Vital Statistics ,77
� `� L A----__
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�Z p i/�11 Jl Dispositionlieu iv C.•.e re4a t n...
Date of Disposition Place of
2 (address)
Cl)Ill
pCL (section) ` (lot num (grave number)
Name of Sexton or Person in Charge of Premises < j�n4 r 10Nii-
Z (please print)
W Signature �c� /� Title Li r' ree.
1
(over)
DOH-1555(02/2004)