Kenny, Angeline ' 1 Litt q
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Angeline A Kenny Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 4,2013 85 War or Dates
t.,. Place of Death Hospital, Institution or
Z City,Town or Village Queensbury Street Address Westmount Health Facility
pManner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined 0 Pending
ILI Circumstances Investigation
W' Medical Certifier Name Title
O Bernardo R.Villajuan
Address
161 Carey Rd,Queensbury,NY 12804
Death Certificate Filed District Number Rpgister Number
City,Town or Village Queensbury 5657 —7
❑Burial Date Cemetery or Crematory
August 6,2013 Pine View Crematorium
El Entombment Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO El Removal and/or Held
and/or Address
H Hold
W
O Date Point of
N El Transportation Shipment
aby 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
H Remains are Shipped, If Other than Above
IAddress
W
O. Permission is hereb granted to dispose of the human rem i described abo�e� s indicated.
Date Issued �j)� c �ll Registrar of Vital Statistics � - % '�-� �„.
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance withthis permit on:
W Date of Disposition MI5 Place of Disposition . ? l`� f�tvs4VnKf ativ!`
2 (address)
W
Cl)
fY (section) (e"n/b�
t (lot number) / (grave number)
Op Name of Sexton or Pers:n in Charge o remises t,l r
Z / ("arse print)
W Signature ,; Title C(Z4 s1 Q.
(over)
DOH-1555(02/2004)