Gregoiro, Philomena NEW YO1K STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
. Name First Middle Last Sex
Philomena M. Gregorio Female
• Date of Death Age If Veteran of U.S. Armed Forces,
s . November 29, 2012 92 War or Dates
t; , Place of Death Hospital, Institution or
Z City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
0 Manner of Death X Natural Cause I 'Accident Homicide Suicide Undetermined Pending
ttf Circumstances Investigation
Ist Medical Certifier Name Title
IVku b A, 516ai41; M�
Address Bk fr IZ'Z2
Death Certificate Filed District Number Register Number
• City, Town or Village Fort Edward,NY )SS 3-5--
Ill Burial Date Cemetery or Crematory
December 3, 2012 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N1 I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
a; Permit Issued to Registration Number
`. Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
• s° 407 Bay Road, Queensbury,NY 12804
: Name of Funeral Firm Making Disposition or to Whom
1 ' Remains are Shipped, If Other than Above
E Address
MI
Permission is h reb granted to dispose of the human ains described boy as indicated.
• Date Issued/)O ` i- Registrar of Vital Statistic i
(signature
District NumberS7 3 Place Fort Edward,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1 2/3/1 2 Place of Disposition Pine vi Pw Cpmet rV
W
(address)
N Mohican 21 D 2
W (section) (lot number) (grave number)
0
G Name of Sexton or Person i Charge of Premises Michael Genier
Z (please print)
W Signature`s Title Superintendent
(over)
DOH-1555(02/2004)