Sennett, Jane B k
NEW YORK STATE DEPARTMENT OF HEALTH 1-u'Bureau of Vital Records ____ % Burial - Transit Permit
Name First Middle Last Sex
Jane B.Sennett .rk, Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/18/2022 84 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
Manner of Death ❑X Natural Cause Accident Ellnicide Suicide Undetermined 7 Pending
W Circumstances Investigation
{W Medical Certifier Name Title
G Courtney Diamond NP
Address
::'spa 170 Warren St,Glens Falls,New York 12801
f °, Death Certificate Filed City Of Glens Falls `-.- strict Number Register Number
City,Town or Village 15601 638
Burial Date Cemetery,Crematory or Facility Name
12/20/2022 Pine View Crematory
=1 Entombment— Address
1. ZCremation Queensbury,New York
Donation
a❑Removal Date Place Removed
and/or and/or Held
F Hold Address
CO
0
d Date Point of
N Transportation
15 by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
LI Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
.- Remains are Shipped,If Other than Above
Address
le
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/19/2022 Registrar of Vital Statistics 9,legan Wolin(ECectronica1TySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /
MI
of Disposition l2I LI 1 Z Z Place of Disposition '1 �.,,��/,r tx tart..
2 (address)
W
1 (section/ /) (lot number) e (grave number)
gName of Sexton or Person in Charge of Premises /-_ G h rite" �'�"rt
(plea e print)
W Signature ( !✓ Title (10511)1t( (
DOH-1555(07/18)p 1 of 2
, 1
:116514
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#