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Provencher, Donna J 4 3g3 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donna J Provencher Female Date of Death Age If Veteran of US.Armed Forces, 04/27/2021 85 Years War or Dates F— Place of Death Hospital,Institution or W City,Town or Village Hudson Falls Village Street Address 1 St Pauls Drive 2E,Hudson Falls Village,New York 12839 p Manner of Death ©Natural Cause 0 Accident ❑Homicide ❑Suicide 0 Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title O Mary Stein NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Hudson Falls Village 5726 8 O Burial Date Cemetery,Crematory or Facility Name 04/29/2021 Pineview Crematory ❑Entombment Address ElCremation Queensbury Town,New York O Donation g ❑Removal Date Place Removed and/or and/or Held F-inHold Address 0 O. Date Point of IA ❑Transportation Shipment p by Common Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 3 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/28/2021 Registrar of Vital Statistics Cynthia A Bardin(Electronically Signed) (signature) District Number 5726 Place Hudson Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z 4?4L W Date of Disposition 11 71111 Place of Disposition 8�+�---- E (address/ LU N (sects) // ftL_ 7 (lot number) (grave number) Q�OName of Sexton or Person in Charge of Pre ���ti (plea print ill Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 314751 Receipt Human remains of delivered on , 20 Pine View Cemetery Repre§tinting the funeral home named on burial permit Official Funeral Directors Reg.or License#