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St John, Heidi A
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Heidi A St John Female Date of Death Age If Veteran of U.S.Armed Forces, 05/02/2021 49 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Corinth Town Street Address 38 Second Street,Corinth Town,New York 12822 Manner of Death ©Natural Cause Accident ❑Homicide Suicide ❑Undetermined ❑Pending UCircumstances Investigation W Medical Certifier Name Title CI Stephen Wrzesinski MD Address 43 New Scotland Avenue MC7,Albany,New York 12203 Death Certificate Filed District Number Register Number City,Town or Village Corinth 4553 ElBurial Date Cemetery,Crematory or Facility Name 05/04/2021 Pineview Crematory El Entombment Address Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or0 El and/or Held f- Hold Address 0 (A ❑Transportation Date Point of p by Common Shipment Carrier Destination 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 Remains are Shipped,If Other than Above 2 Address Ir W (1' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/04/2021 Registrar of Vital Statistics Brenda L Peris(Electronically Signed) (signature) District Number 4553 Place Corinth, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 40\--- L.WDate of Disposition 5 S �'Z, Place of Disposition �,�� (address) W (section) (lot number) (grave number) Name of Sexton or Person in Charge of Pre s P,,:hot_ 5!'"12► . Z (pleape print) W Signature �`� Title C . DOH-1555(07/18)p 1 of 2 — Public Health Law Sec. 4145(2b) 1 I 4 7 Jl' Receipt {ti . 1 ,- Human remains of ' delivered on , 20 I — 1 .. --- .., , Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# 1