Willard, Teena L LF')
NEW YORK STATE DEPARTMENT OF HEALTH -s Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Teena L Willard Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/09/2022 64 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Albany Street Address Albany Medical Center Hospital
(a Manner of Death Natural Cause Accident ❑Homicide 0Suicide Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Sean Conner DO
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 2350
HBurial Date Cemetery,Crematory or Facility Name
10/12/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
❑Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
0
n- Date Point of
elf❑Transportation
0 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
1— Remains are Shipped,If Other than Above
g Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/12/2022 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed)
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition /(l .-/3.-2&z L Place of Disposition P,)1 et);Q C re,,.ie.--4)11
2 (address)
W
CC CC (section) (lot number) (grave number)
re
Name of Sexton or Person i Charge of Premises I t ► �" e`
Z / - (please print)
W Signature 1/ Title 6.- ,r1- j/ C,$)0f'ri
DOH-1555(07/18)p 1 of 4
f '1 Cy 'f9
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#