Hendley, Donna NEW YORK STATE DEPARTMENT OF HEALTI-( Sy3
Vital Records Section Burial - Transit Permit
77 Name First Middle Last Sex
Donna Ann Hendley Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 21, 2014 69 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 1....j Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
-
Medical Certifier Name Title
Gamal Khalifa, Dr.
` Address
or 100 Park Street Glens Falls 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls S 6 n I i/ 3
❑Burial Date Cemetery or Crematory
September 23, 2014 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
, Carrier
A ❑ Disinterment Date Cemetery Address
x Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
_: Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
` Remains are Shipped, If Other than Above
Address
LL` Permission is hereby granted to dispose of the human remains described above as,indicated.
Date Issued off. (Z"Z t f L.-Registrar of Vital Statistics LA) C Q` 1/0.1tr\-fer"
(signature)
50 ( 6 (Q,..s Ft \ g / )y
District Number � Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/23/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /i . (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ZA nsfitri,e.4. ""
,> // (please print)
Signature 'L -/l+S Title Cri&A94
(over)
DOH-1555 (02/2004)