Cassidy, Maureen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
-Maureen C. CaQQ- Female
Date of Death Age If Veteran of U.S. Armed-Forces,
Dec. 13. 2012 51 War or Dates do
166. Place of Death Town of Mt. Pleasant Hospital, Institution or Westchester Medical Center
WCity, Town or Village Street Address Valhalla, New York
•p Manner of Death Llatural Cause El Accident 0 Homicide El Suicide 0 Undetermined El Pending
LCJ Circumstances Investigation
tu Medical Certifier Name Title
Q David Wolf MD
Address
Westchester Medical Center, Valhalla, New York 10595
Death Certificate Filed District Number Register Number
City, Town or Village Town of Mt. Pleasant 5957 655
`':`[ urial Date Cemetery or Crematory
;:[]Entombment Dec. 18, 2012 St_ Alphonsus CPmitPry
Address
❑Cremation QQuueenshury, NPw York
Date Place Removed
Z Removal and/or Held
0❑and/or Address
f= Hold
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0 Date Point of
05 El Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
giiiQ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home, 01596
`: Address
Nt 407 Bay Road, Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
rF-- Remains are Shipped, If Other than Above
2 Address
i
W.
L : Permission is hereby granted to dispose of the hums ains describe above as in 'cated.,
iiii Date Issued 12/14/2012 Registrar of Vital Statistics a g,c, Cad(C
(signatur
liili District Number 5957 Place One Town Hall Plaza, Valhalla, New York 10595
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition IA1���1. Place of Disposition Jt 1 �Of SU')
2 (address)
W < ..
Q (section)
(lot number) (grave number)
p Name of Sexton or Person in Charge of Premises iv,\ `
Z (please print)
W Signature Title J
(over)