Denue, Olive NEW YORK STATE DEPARTMENT OF HEALTH I
Vital Records Section * Burial - Transit Permit
Mi Name First Middle Last Sex
Olive E. Denue F
Date of Death Age If Veteran of U.S. Armed Forces,
December 23, 2012 89 War or Dates No
Place of Death Hospital, Institution or
City, Tool ( ) M 4X Plattsburgh Street Address Clinton County Nursing Home
a Manner of Death®Natural Cause 0 Accident ❑Homicide ❑Suicide ri"—I Undetermined ❑Pending
11JCircumstances Investigation
O.
in Medical Certifier Name Title
44 Glen Schroyer MD
Address
675 Route 3, Plattsburgh, NY 12901
pi Death Certificate Filed District Number Register Number
iil
City, Tovtl4X Plattsburgh 901
0 Burial Date Cemetery or Crematory
12/24/2012 Pine View Crematory
i ['Entombment Address
iiiiiiiii®Cremation Queensbury, NY
Date Place Removed
9 ❑Removal and/or Held
and/or Address
E Hold
C
0 Date ' Point of
d ❑ p Trans ortation Shipment
Et by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Ni, Permit Issued to Registration Number
Name of Funeral Home Brewer- MIller Funeral Home 0119 9
Address 24 Church St. , Lake Luzurne, N.Y. 12846
gi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
M. Address
CC:
t
Permission is here y gr nted to dispose of the human rem i descri e as'n 4. J
i�caatted.��
[ Date Issued Registrar of Vital Statistics SL
(signature)
: : District Number 901 Place City of Plattsburgh
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111• Date of Disposition i i-it,-t1 Place of Disposition -Pin,,Uotto Ln 'fa N 4
(address)
Ili
U)
CC (section) / (lot number) (grave number)
Name of Sexton or Person in Charge of Premises nP��t
2Tease print)
Wm Signature4..._. 4-- Title C�eitA-
(over)
DOH-1555 (02/2004)