Dee, Judith Y 4 , q5+
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section fi
Burial - Transit errni
W1 Name First Middle Last Sex
Judith A. Dee Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 10,2017 69 War or Dates
'lf Place of Death ,Hospital, Institution or
City, Town or Village Queensbury Street Address 29 Gentry Lane
Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificate Filed District Number:::. Regigter Number
City, Town or Village Queensbury, NY 5657 )�/
0 Burial Date Cemetery or Crematory
June 13, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 21Quaker Road, Queensbury,NY 12804
Date Place Removed
OZ ❑Removal and/or Held
and/or Address
H Hold
co
O Date Point of
N ❑Transportation Shipment
'p 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 Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
S. Address
S
i
Permission is hereby granted to dispose of the human r mains described bpve as indicated.
Date Issued I I Is) Registrar of Vital Statistics c.__ ci ,
(signature) '
District NumberSligsn Place ‘ 0
I certify that the remains of the decedent identified above were disposed of in ac rdance with this permit on:
Z
ui Date of Disposition i,j 13117 Place of Disposition Riu tt../ Cr+mAgli...
(address)
W
U)
CL
(section) //(Igt number) (grave number)
pName of Sexton or Person in Charge of Premises 1'1r. vA/1f
Z (please printf
W
Signature �1 y- Title reK.Pit l ,
(over)
DOH-1555(02/2004)
Town of Queensbury
Certification of Cremation
aPine View Cemetery and Crematory
This certifies that the remains of: Judith Dee
were cremated on June , 13 20 17 at the Pine View
(Month) (Day)
Crematorium, Queensbury,New York, and these are the cremated remains of said body.
Date of Death June , 10 20 17 Age 69
(Month) (Day)
Funeral Home Singleton Sullivan Potter Registered No. 456
dir
(Authorized Signature)