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Hensen, James R.
$ s2q it i NEW YORK STATE DEPARTMENT OF HEALTH `'` Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James R. Henson Male Date of Death - Age If Veteran of U.S.Armed Forces, 06/27/2021 82 Years War or Dates F Place of Death Hospital,Institution or Z City,Town or Village Lake Luzerne Town Street Address 195 Gage Hill Road, Lake Luzerne Town, New York 12846 UJ p Manner of Death ©Natural Cause ❑Accident 1=1 Homicide Suicide 0 Undetermined 0 Pending W Circumstances Investigation C.) ILI Medical Certifier Name Title CI Ryan Donnelly DO Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Lake Luzerne 5656 10 EiBurial Date Cemetery,Crematory or Facility Name 06/29/2021 Pine View Crematory El Entombment Address ElCremation Queensbury Town, New York EIDonation Date Place Removed ZO Removal and/or Held I- - and/or CO Address 0 Date Point of (/) El Transportation Shipment Q by Common Carrier Destination El Disinterment Date Cemetery Address Date Cemetery Address EiReinterment Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom i— Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued Q6/29/2021 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed) (signature) District Number 5656 Place Lake Luzerne, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H t e.,,_ W Date of Disposition (o�I Z1 Place of Disposition address W N (section) (tt number) (grave number) 0 0 i4 f tJ 44,1 Name of Sexton or Person in Charge of Pre .ses (As.,please p nt/ z /_, l .grwt W Signature Title DOH-1.555(018)p 1 of 2 .) ,IA897 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#