Tennyson, Hilda NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Hilda. V. Tennyson F
Date of Death Age If Veteran of U.S. Armed Forces,
11-3-97 78 War or Dates NA.
Place of Death Hospital, Institution or
City, Town or Village Johnsburg Street Address ATCNH
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Dr. Reali MD
Address
Ei'-PN, TAorth Creek,NY
Death Certificate Filed District Number 55
Register Number
City, Town or Village Johnsburg 6
Date Cemetery or Crematory
❑Burial 1 1-3-97 Pine View Crematory
D Cremation Address Queensbury,VZ
Date Place Removed
❑Removal and/or Held
... and/or Address
}" Hold
Q Date Point of
N ❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Adirondack Cre ation Assoc. 02168
Address
Warrensburg,NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re s des r' ed b ve as indicated.
Date Issued 11-3-97 Registrar of Vital Statistics
(signature)
District Number
Place T/O Johnsburg,!�iY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
' r /JT l
Date of Disposition� Place of Disposition �/'MAE l�kJ � �/� /O /
(address)
i11
0
ift (section) "�(lo number)
0 Name
Name of Sexton or Person in Charge of Premises ELAM"_Aw ��/ 4 / (grave number)
(please print)G
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61