Down, Beverly ^v
5
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
-- Name First Middle Last Sex
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•• . Beverly Renee Down Female
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Date of Death Age If Veteran of U.S. Armed Forces,
JJanuary 14, 2017 64 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
5 Manner of Death in Natural Cause ❑Accident Homicide Suicide I Undetermined 1 Pending
Circumstances Investigation
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./, Medical Certifier Name Title
^' Asim Chaudry MD
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Address
100 Park Street,Glens Falls,NY 12801' 2 Death Certificate Filed Districtber `�I Register Number
City, Town or Village yy 31
❑Burial Date Cemetery or Crematory
January 17, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
Hold
CO
O Date Point of
•
O. n Transportation Shipment
a by Common Destination
Carrier _
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address --
W. Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
. Address
• 407 Ba Road, ueensbur , NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
4 r
Permission is hereby granted to dispose of the human remains described above,as indicated.
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a Date Issued { /I -7 I 2017 Registrar of Vital Statistics W cam,--k "-/\-"-e-
et (signa re)
pa District Number S b O I Place
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
cmDate
of Disposition dig in Place of Disposition 1,i z�Y n r-.✓ Crw e-0rir,,,.
(address)
LU
pce (section) /it_ lot number (grave number)
Name of Sexton or Person in Charge of Pr mises � �+ �61
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Signature Title CO-Miltit
(over)
DOH-1555(02/2004)