Calvert, Elizabeth NE' / YORX STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elizabeth Calvert Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 25,2013 67 War or Dates
/ 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 n Homicide n Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Darci Gaiotti-Grubbs M.D.
, Address
Death Certificate Filed District Number Registgz.Number
fr,
City, Town or Village Glens Falls 5601 i
El Burial Date Cemetery or Crematory
April 30, 2013 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ri Removal and/or Held
and/or Address
H Hold
o)
O Date Point of
con Transportation Shipment
p 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
s 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 s rib d ov 'ndicated.
Date Issued eNA'�/3 Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 4/3 0/1 3 Place of Disposition Pine View Cemetery
2 (address)
W
1) Erie 45 D 2
(section) (lot number) (grave number)
Q Name • -'"x •n or Perso ' Charge of Premises Connie L. Goedert
Z (please print)
W
Signal:' - 4/Lice.2 �- I Title Superintendent
(over)
DOH-1555(02/2004)