Humphrey, Carriebelle NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First - Middle Last Sex
ac c ke <.X\t, 'Kay' Humphrey Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 9, 2014 85 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause 0 Accident I I Homicide ❑Suicide n Undetermined n Pending
#�f Circumstances Investigation
V Medical Certifier Name Title
P Mathew Varughese,MD
Address
Glens Falls,NY 12801
Death Certificate Filed District Number Regi ��umber
City, Town or Village Glens Falls,NY 5601
❑X Burial Date Cemetery or Crematory
January 15, 2014 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
U)
O Date Point of
NElTransportation Shipment
p by Common Destination
Carrier
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
2 Address
re
1UCL
" Permission is hereby granted to dispose of the human remains des ibe above a 'cated.
Date Issued O/ /3 Its/r' Registrar of Vital Statistics
i
(srgnature)
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:
Z
W Date of Disposition 1 /1 5/1 4 Place of Disposition Pine View Cemetery
2 (aaaress)
N Mohican 1C 2
re (section) (lot number) (grave number)
O• Name of S ton or Person in Charge of Premises Connie L. Goedert
Z (please print)
W Signatur itit-�+' .t Title Superintendent
(over)
DOH-1555(02/2004)