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Henderson, Joan NEW YORK STATE DEPARTMENT OF HEALTH li4 f Vital Records Section Burial - Transit Permit Name First Middle Last Sex Joan Henderson Female Date of Death Age If Veteran of U.S. Armed Forces, July 7, 2013 70 War or Dates tag Place of Death Hospital, Institution or RUC ii r City, Town or Village Moreau Street Address 17 /��yc16NT2 1311 Statc tc 9 Manner of Death X❑ Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title John E. Lukaszewicz, Dr. Address 'i 84 Broad Street Glens Falls, NY 12801 Death Certificate Filed District Number`7 1 a. RegisterNymber iii City, Town or Village Moreau (P �4 El Burial Date Cemetery or Crematory July 12, 2013 Pine View Crematory ❑Entombment Address v -®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 P. ❑ Disinterment Date Cemetery Address " El Reinterment Date Cemetery Address r Registration Number �i Permit Issued to 9 ii i Name of Funeral Home M.B. Kilmer Funeral Home 01078 ,iAddress 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 e, Permission is hereby granted to dispose of the human re -ns described above as indicated. k ii' Date Issued rl- I ) -j_j Registrar of Vital Statistics . ! fyl n_q M - .. (signature) „-` District Number 1/576z Place ( / J.-h)DS oN( Jr.,$ uTT/ 6L-CMS FA/ S Ai j )2'©-3 F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 07/12/2013 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) `lot number) C (grave number) of Pr ises they.- V\eo _1J. Name of Sexton or Person in Charge � N�I (pase print) 171r Title Ctek Signatu e (over) DOH-1555 (02/2004)