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Bray, Carol NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit rermit Name First Middle Last Sex Carol MacGregor Bray , Female Date of Death Age If Veteran of U.S. Armed Forces, August 17, 2017 72 War or Dates n/a },, Place of Death Hospital, Institution or tZ City, Town or Village Queensbury Street Address 240 Rockwell Road ,p Manner of Death X Natural Cause I 1 Accident n Homicide n Suicide n Undetermined Pending Circumstances Investigation G Medical Certifi Name _._, ' Title rD Address ` 1 LSLX),.. \13GA) \ ` t-z4 �� Death Certificate Filed I i s t r i c t Number Rp ist umber City, Town or Village Queensbury, NY 5657 ❑Burial Date Cemetery or Crematory August 23, 2017 Pine View Crematorium ❑Entombment Address ©Cremation 51 Quaker Road, Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold N 0 Date Point of NTransportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address [1]Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped, If Other than Above a Address CL iW A. Permission is her by granted to dispose of the human remains described ab ve as indicated. Date Issued�-t I 1 Registrar of Vital Statistics C _ct C tl.(-A___ --(I) r---- (signature) District Number(-)(c `) Place O LAB c ((_,i p;; -ram 13 I certify that the remains of the decedent identified above were disposed of in accor ance ith this permit on: W Date of Disposition Stivd , Place of Disposition °Pnt0et-/ 4",itorrw. W (address) U) CL (section) J (lot number- (grave number) p Name of Sexton or Person in Charge of Premises /i`r„#uflrr .)t n^ t Z (pldase print) IllSignature 's .d Title G24,SMAW— (over) DOH-1555(02/2004)