Homkey, Sally NEW YORK SATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sally Ann Homkey Female
a ' Date of Death Age If Veteran of U.S. Armed Forces,
May 31,2012 78 War or Dates
Place of Death Hospital, Institution or
rCity, Town or Village Glens Falls Street Address 59 Grant Ave.
Manner of Death n Natural Cause n Accident n Homicide Suicide Undetermined Pending
L° Circumstances Investigation
Medical Certifier Name Title
0. Dr.Gillani,MD
Address
Park Street,Glens Falls,NY
Death Certificate Filed District Numbe5601 Register Num er
City, Town or Village Glens Falls 60 )
®Burial Date Cemetery or Crematory
June 5, 2012 Pine V_iew Cemetery
D Entombment 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
Wn Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
;=s Permit Issued to Registration Number
,:x 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
te
;tt3
'`' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6 1 ! / 'Z Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tu Date of Disposition 6/5/1 2 Place of Disposition Pine View Cemetery
2 (address)
W
U) Ondawa 3 E 1
Ce (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises Michael Genier
Z 91 • (please print)
W Signature ( `-, Title Superintendent
(over)
DOH-1555(02/2004)