Hensley, Deanna - , V cot
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Deanna Kay Hensley Female
Date of Death Age If Veteran of U.S.Armed Forces,
6/18/2018 40 War or Dates NA
F. Place of Death , Hospital, Institution or
Z City, Town or Village Glens Falls j Street Address 32 Grove Avenue
pManner of Death U Natural Cause I j Accident ❑Homicide E Suicide ❑Undetermined n Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Robert Love,MD
Address
Iron Gate Center,Glens Falls,NY 12801
Death Certificate Filed District Number I Register Numbs
City, Town or Village Glens Falls,NY SCDO1 0y
❑Burial Date Cemetery or Crematory
June 20,2018 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
H Hold
N
O Date Point of
O.
n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n 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
i— Remains are Shipped, If Other than Above
2 Address
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6`f q 12c re< Registrar of Vital Statistics W
(signature)
District Number S 6,c1) Place 6 Cs.--v._5
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IJJ Date of Disposition 6'if Its Place of Disposition ruin , fnwTo.„
Ili (address)
CO
O (section) ( t number) (grave number)
pName of Sexton or Person in Charge of Premises lr. . 5....-4i
Z (plea print)
W
Signature Title Wei rt.-4
4 _
(over)
DOH-1555(02/2004)