Lawson, Mary t .
NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
7 V Name First Middle Last Sex
Mary Lois Lawson Female
'' Date of Death Age If Veteran of U.S. Armed Forces,
M December 11 2016 87 War or Dates
1 Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 62 Wincrest Drive
Manner of Death I,(I Natural Cause ( (Accident n Homicide Suicide 1 Undetermined Pending
r.
Circumstances Investigation
)11-* Medical Certifier Name Title
;$. Patricia Auer
Address
Care Rd, I ueensbu NY 12804
. Dea e ' icate Fil D' fct Number glstei Number
City Town o Village 1 L.Q. .c„. ) � I
D Buria Date Cemetery or Crematory
El Entombment December 15,2016 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZI I Removal and/or Held
and/or Address
Hold
N
0 Date Point of
u
)Q Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
f Reinterment Date Cemetery Address
,-1 Permit Issued to Registration Number
f Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
,fij 407 Bay Road, Queensbury, NY 12804
V Name of Funeral Firm Making Disposition or to Whom
: Remains are Shipped, If Other than Above
"z Address
Permission is hereby granted to dispose of the human remain described ab ve s indicated.
ry Date Issued (v k,� �l(c,Registrar of Vital Statistics n Li
} District NumbecCo fl Place C.30.,s2Q,,a„,.,,,,,I.,
sir
F- I certify that the remains of the decedent identified above were disposed of in accordanc- ith th . permit on:
Z
Date of Disposition 1 2/1 5/1 6 Place of Disposition Pine View Cemetery, Queensbury, NY
III (address)
CO Erie 64A 4
CL
(section) (lot number) (grave number)
Z Name of Sexton or Person in Charge of Premises Connie L. Goedert
(please print)
W Signature 2 .Q_4N Title Cemetery Superintendent
(over)
DOH-1555(02/2004)