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Orta, Maria Its NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Maria Rose Orta Female Date of Death Age If Veteran of U.S. Armed Forces, March 21,2014 90 War or Dates Place of Death Hospital, Institution or Z City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home Manner of Death 'Xi Natural Cause Accident Homicide U Suicide n Undetermined n Pending tti Circumstances Investigation }w Medical Certifier Name Title Philip Gara,MD Address Fort Edward,NY 12828 Death Certificate Filed District Number Regi ter_ymber City, Town or Village Fort Edward,NY 7S� ©Burial Date Cemetery or Crematory March 25,2014 Pine View Cemetery ❑Entombment Address El Cremation Quaker Road, Queensbury, ,NY 12804 Date Place Removed Z Fl Removal and/or Held and/or Address F' Hold N 0 Date Point of I I Transportation Shipment p by Common Destination Carrier Ei 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 f Permission is reb gr ted to dispose of the hums sins descri abov as indicated. Date Issue Registrar of Vital Statistic ��J Le l (signs ure District Numbe j75 Place Fort Edward,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: LU Date of Disposition 3/2 5/1 4 Place of Disposition Pine View Cemetery (address) Single Interment 118 2 (section) (lot number) (grave number) pName of Sex on or Person in Charge of P ises Connie L. Goedert Z (please print) W Signature &butC Pc Title Superintendent (over) DOH-1555(02/2004)