Gieser, Priscilla NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Priscilla Gieser Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 26,2013 97 War or Dates
,,, Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address Stanton Nursing& Rehab Centre
p Manner of Death Natural Cause Accident Homicide n Suicide L Undetermined �Pending
W Circumstances Investigation
G
Medical Certifier Name Title
Roslyn Socolof
Address
Stanton NH, 152 Sherman Ave,Glens Falls,NY 12801
Death Certificate Filed Queensbury District Number Regis Number
City, Town or Village 5657 !!
0 Burial Date Cemetery or Crematory
❑Entombment September 28,2013 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
ZZ Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N ❑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
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
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a
Permission is hereby granted to dispose of the human e ains described bpy,� as indicated.
Date Issued 12-''-'j l���Registrar of Vital Statistics �L--�, C{ v l\jzf_
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above re disposed of in accordance with this permit on:
Z
Ww Date of Disposition L/2gP,.5 Place of Disposition t- 4e4..) d7a676-kif
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NOe� :3 -( z
re
ectio (lot number p 1, (grave number)
Z Name of S n or Person in Charge of Premises ` n� 1�
4 L. 6EJ
W (p ase print)
Signatur E A$ I.!. __ Title (144,tzt..ii
IP
(over)
DOH-1555(02/2004)