Sherman, Christina i. NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
-;:n;:- Name First Middle Last Sex
Christina Alice Sherman Female
'> Date of Death Age If Veteran of U.S. Armed Forces,
' July 22,2017 71 War or Dates
1, Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 14 Barber Ave
Manner of Death n Natural Cause n Accident n Homicide ❑Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Timothy Murphy,Coroner
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657 ri J._,
®Burial Date Cemetery or Crematory
❑Entombment July 29,2017 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZO ❑Removal and/or Held
F and/or Address
Hold
N
O Date Point of
EL N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑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
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Vat 1 ao 11 Registrar of Vital Statistics ' al � - - - -
(signature)
District Number 55 le 51 Place OU-t-cf‘SbVil
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
Z
W Date of Disposition 29I/9 Place of Disposition
2 (address)
CO 0146 he- 3,3
re
n) (lot number) (grave number)
p0 Name of Se n or Person in Charge of Premises (B'(/AJ'‘ L /'- 0-41 j
Z C;;462,44.4/ e seprint) aicLe,ic
W Signature `l '-,g Title
(over)
DOH-1555(02/2004)