Avon, Shirley • NEVVYORK STATE DEPARTMENT OF HEALTH
-Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shirley AvDn female
Date of Death Age If Veteran of U.S. Armed Forces,
06/16/2006 81 War or Dates n/a
Place of Death Hospital, Institution or
jxeitg, Townxxals�aili c Queensbury Street Address Stanton Nsg. & Rehab. Ct
141 Manner of Death g
] ®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑ endin
I Circumstances Investigation
tu Medical Certifier Name -_ Title
P. Suzanne Blood,MD
Address 14 Manor Drive, Queensbury, NY 12804
Death Certificate Filed District Number Rggister Number
City, Town or Village SIDC . �3
mii L1Burial Date Cemetery or Crematory
06/19/2006 Pine View Cemetery
❑Entombment Address
,Cremation Queensbury, NY 12804
iiiigiiiiiii Date Place Removed
2❑Removal and/or Held
Cj and/or Address
tt Hold
411
Q Date Point of
CA
CL
❑Transportation Shipment o by Common Destination
IiiiIii Carrier
❑Disinterment Date Cemetery Address
gigEl Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01682
Address 407 BayRoad,
, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
to
i Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issuek.S. `ts,\DC4 Registrar of Vital Statistics -KCA.,,-, Q - CKIS n.,,,
(signature)
iiiM District Numb( Place 'c , , b. - b
I certify that the remains of the decedent identified above w re disposed of in accor ance with this permit on:
Z
Il Date of Disposition 6/19/06 Place of Disposition PINE VIEW CEMETERY,QUEENSBURY NY
(address)
ill
tO HUDSON #3 -1=.A 1
cc (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises M I CHAEL 6EN I ER
z. 9.J.,AmAx,
(please print)Signature141 Title S I I PT.
(over)
DOH-1555 (02/2004)