Pettersen, Sara r '
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First . Middle Last Sex
Sara E. Pettersen I Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 5, 2012 93 War or Dates
ix: Place of Death Hospital, Institution or
City, Town or Village Glens Falls,NY Street Address Glens Falls Hospital
Manner of Death n Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
. Marvin Davidowitz,MD
Address
100 Park Street,Glens Falls,NY 12801
;;;a Death Certificate Filed District Number Register N)i ber
;di` City, Town or Village Glens Falls,NY 5601 Yeel
0 Burial Date Cemetery or Crematory
❑Entombment October 9,2012 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
Z n Removal and/or Held
O and/or Address
H Hold
N
0 Date Point of
NI J Transportation Shipment
'p by Common Destination
_ Carrier
n Disinterment Date Cemetery Address
n 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
>4+ Remains are Shipped, If Other than Above
Address
:: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10 I CI/ 2_ Registrar of Vital Statistics ( C
(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:
WDate of Disposition 1 0/9/1 2 Place of Disposition Pine View Cemetery
W (address)
3 5 G 3 CL (section) (lot number) (grave number)
a Name of Sexton or Person in Charge of Premises Michael Genier
Z 1�"e 9..i...vv:A.A.N. (please ntt)
WSignatureTitle Superintendent
(over)
DOH-1555(02/2004)