Stark, Norma NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Norma O. Stark Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 4, 2013 90 War or Dates
i Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause n Accident ❑Homicide Suicide Undetermined Pending
Circumstances Investigation
a Medical Certifier Name Title
F Kamal,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Regist r ber
City, Town or Village Glens Falls,NY 5601
❑X Burial Date Cemetery or Crematory
El Entombment November 7, 2013 Seeley Cemetery
Address
❑Cremation Ridge Road, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
Nn Transportation Shipment
a by Common Destination
Carrier
n 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
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
,
Date Issued 1 i j 6/43 Registrar of Vital Statistics
(sign ure)
.J
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition 1 1 113 Place of Disposition
W (address)
N
re
(section) (lot ber) (g number)
• Name of Sexton or Person in Charge of Premises I
Z g _-` /f
W J . pleas print)
Signature .U\ Title 1._0 A ;l ay. ,---
(over)
DOH-1555(02/2004)