Fisher, Joan NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last -Z Sex
Joan W. Fisher Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 26,2013 79 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address Stanton Nursing & Rehab Centre
pManner of Death a Natural Cause n Accident Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
w; Medical Certifier Name Title
Roslyn Socolof
Address
Stanton NH, 152 Sherman Ave,Glens Falls,NY 12804
Death Certificate Filed District Number Register tuber
City, Town or Village Queensbury 5657 J
❑Burial Date Cemetery or Crematory
Q Entombment Address
❑Cremation
Date Place Removed
OC Removal and/or Held
and/or Address
t: Hold
0 Date Point of
u) Li 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
F Remains are Shipped, If Other than Above
re; Address
tit
n` Permission is hereby granted to dispose of the human remains describeda� ove as indicated.
Date Issued"1 I`: 7!C3OR Registrar of Vital Statistics _ ` . 3
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified abov re disposed of in accordance with this permit on:
Lti j I
Date of Disposition a/JO 26(.3 Place of Disposition 1' (1.e 'Yt 0,6
( ((( .(address
coLih NA,s. 3 1 /.
O (s number (grave number)
� k n) (lot numb• Name of Sext or Person in Charge of Premises /'t//u{ I. Qack ,
W (please t) p;
Signature fu/u_Q eiCLUirTitle
(over)
DOH-1555(02/2004)