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Stone, Sandra f NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Sandra C. Stone Female Date of Death Age If Veteran of U.S. Armed Forces, 9/22/2018 78 War or Dates NA Place of Death Hospital, Institution or WCity, Town or Village Glens Falls,NY Street Address 255 South St.,Glens Falls,NY p Manner of Death n Natural Cause n Accident n Homicide Suicide n Undetermined n Pending W Circumstances Investigation W` Medical Certifier Name Title O Glen Anderson,PA Address 161 Carey Rd.,Queensbury,NY 12804 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls,NY CA Li 5CD ®Burial Date Cemetery or Crematory September 26,2018 1 Pine View Cemetery ❑Entombment Address ❑Cremation Quaker Road,Queensbury,NY 12804 Date Place Removed Z —Removal and/or Held O and/or Address F Hold N p Date Point of N I Transportation 1 Shipment p by Common Destination Carrier n Disinterment Date 1 Cemetery Address (i 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 I- Remains are Shipped, If Other than Above 2 Address C W O. Permission is hereby granted to dispose of the human remains described above as indicated. 0 Date Issued 9 jZStf i%' Registrar of Vital Statistics , c .v e- k/l?,.".. it- (signatur ) District Number 5 b© 1 Place (;',) CSiA'S k lS y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z 9 2 6 Place of DispositionCemetery W Date of Disposition / /201 8 p Pine View Queensbury W (address) Mohican 12-E 2 M (section) (lot number) (grave number) O▪ Name of S xton or Perso ' Charge of Premises Connie L. Goedert Z , � r (please print) W Si nature �/d�-� Title Cemetery Superintendent 9 (over) DOH-1555(02/2004)