Sliva, Josephine NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section
Burial - Transit Permit
.n
Name First Middle Last Sex
V.r Josephine F. Silva Female
' r Date of Death Age If Veteran of U.S. Armed Forces,
"`k August 17,2015 86 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 ❑Suicide n Undetermined [1 Pending
Circumstances Investigation
L, Medical Certifier Name Title
Michael Miles M t�
,J
Address
r 100 Park Street,Glens Falls,NY 12801
-f Death Certificate Filed District Number�/� Register�V ber
'`` City, Town or Village Q/ t�
LI Burial I Date Cemetery or Crematory
❑Entombment August 21, 2015 I St. Alphonsus Cemetery
Address
❑Cremation Pine Street
Date Place Removed
ZZ• I I Removal and/or Held
and/or Address
H Hold
N
Q Date Point of
(53 ❑Transportation Shipment
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
.1 Remains are Shipped, If Other than Above
Address
;,;.: Permission is hereby ranted to dispose of the human remains de r b d ove i icated.
a:a
Date Issued 0/9 Z®is Registrar of Vital Statistics e�
: (signature)
District Number S40/ Place agt-Po `/3'. by
{
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z -' " �
iw Date of DispositionA?.1\kt-
Place of Disposition r, e . Ca3 Q e Asbwy i�"<W (address)
Ose ion) r �(of number) (grave number)
p Name of Sexto Person in Charge of Premises & v.1
Z (p ase print)
W Signature �_ Title ON r.".Gcl
(over)
DOH-1555(02/2004)