Emery, Gertrude ` NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
;f+= Name First Middle Last Sex
ft, Gertrude M. Emery Female
r Date of Death Age If Veteran of U.S. Armed Forces,
�rrr September 9, 2016 91 War or Dates NA
;..;z Place of Death Hospital, Institution or
• City, Town or Village Glens Falls Street Address Glens Falls Hospital
..y Manner of Death n C E n Undetermined n Pending
�� X Natural Cause AccidentHomicide Suicide 9
Circumstances Investigation
s, Medical Certifier Name Title
:. James North MD
'` Address
100 Broad Street,Glens Falls,NY 12801
0 Death Certificate Filed District Number 1 Register Number L'60
{ City, Town or Village Glens Falls,NY
LJ Burial Date Cemetery or Crematory
❑Entombment September 14, 2016 Pine View Cemetery
Address
❑Cremation Quaker Road Queensbury, Queensbury, NY 12804
Date Place Removed
z U Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Li 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
f Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address —
I
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 I i a / /6 Registrar of Vital Statistics CAD CA &4'v k.A),_
a : (signature)
District Number 5 6 0 j Place 6 iszAr„s cc, t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 9/1 4/1 6 Place of Disposition Pine View Cemetery, Queensburys NY
W (address)
Mohican 41F 1
cc
0 (section) (lot number) (grave number)
p Name of Se or Person i •- ge of Premises Connie L. Goedert
Z • / / (please print)
Lu
Signatures ,�-¢.o Title Cemetery Superintendent
(over)
DOH-1555(02/2004)
EMERY (LF)
NAME Gertrude M. Emery Age: 91 . ._
Lot Owner: James & Gertrude Emery
Lot# 41F, Mohican Grave# 1
Case: Concrete
Died: 9/9/2 01 6 Interred:9/1 4/2 01 6
Funeral Home: Singleton Sullivan Potter
Cemetery: Pine View
Emery
Lot No. 41-F
'dress Section No.
1 Baker Road Oueensbury NY 12804
wrier James E. & Gertrude M. Emery Plot Mohican
ate 4/13/95
Approx. 100 Superficial ft. @
)cation Bounded North by Zwick, South by Vacant , East by Leonbruno , West by Ensor &
Lettus
mner Posts
marks
eed No. (and changes) 2661
lyment Record Paid in Full 4/13/95 ( $10 5 0 . 0 0 )
ecord of Interments
_ / .[
Gertrude M F.mary 9/14/16 FB
James E. Emery, Jr. 1/24/05
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