O'Connor, Patricia NEVEJ YOR STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patricia H. O'Connor Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 25, 2014 71 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls,NY Street Address 546 Glen Street
Manner of Death n Natural Cause n Accident 0 Homicide Suicide n Undetermined n Pending
IA Circumstances Investigation
Medical Certifier Name Title
Robert Hogan,MD
Address
Queensbury,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 3 T)
®Burial Date Cemetery or Crematory
[I]Entombment June 30, 2014 Pine View Cemetery
Address
0 Cremation Quaker Road,Queensbury,NY 12804
Date Place Removed
Z El Removal and/or Held
and/or Address
F' Hold
N
0 Date Point of
N n Transportation Shipment
'p by Common Destination
_ Carrier
ii
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
4" Permission is hereby granted to dispose of the huma remai describ above as ' dic.ted.
Date Issued f / �O/Registrar of Vital Statistics Dl�Q�l7 �:
f (signature)
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:
W Date of Disposition 6/30/201 ,lace of Disposition Pine View Cemetery
2 (addre s)
W Uncas Sec. 22 19 8
IY (section) (lot number) (grave number)
pName of Sex n or Person in Charge of Premises Connie L. Goedert
Z (please print)
W ' Superintendent
t Signature ' tutu_ Vc1pCte Title
(over)
DOH-1555(02/2004)