Cole, Ruth ---4t5C-f) # Sir
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
« Name First Middle Last Sex
Ruth Jane Cole Female
Date of Death Age If Veteran of U.S. Armed Forces,
08/01/2017 97 Years War or Dates
F- Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death a Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
A Gamal Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 416
El Burial Date Cemetery or Crematory
08/07/2017 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Z ❑Removal and/or Held
F and/or Address
Hold
0 Date Point of
CL Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
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
T Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
Ce
a" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/02/2017 Registrar of Vital Statistics Rp6ertACurtu cEfectronicalfysigned
(signature)
s District Number 5601 Place Glens Falls, New York
1- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LLI Date of Disposition eh' fl Place of Disposition f tt.\J 4✓ Cv..+0ot0..,
W (address)
U)
IX (section) of number) (grave number)
pName of Sexton or Person in Charge of remises RI...) ,.. i.NoviVI
Z ,!! (plea print)
W Signature G� Title !fit tMtl@IL
(over)
DOH-1555 (02/2004)