Russell, Veronica NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
ass
Veronica Lynn Russell Female
OA Date of Death Age If Veteran of U.S. Armed Forces,
January 5,2018 46 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Glens Falls,NY Street Address 32 Chester Street
Manner of Death Natural Cause C Accident 0 Homicide [—Suicide n Undetermined n Pending
Circumstances Investigation
-`; Medical Certifier Name Title
Timothy Murphy,Conoer
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 IIJJ
®Burial Date Cemetery or Crematory
❑Entombment January 10,2018 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ri Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
0 [1Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
ri Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter 01596
%z
5
Address
3 407 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 descr-bed abov as ii icated.
4. Oi Date Issued 000/� Registrar of Vital Statistics �4 a G-a.,,
0.-Yr
(signature)
District Number Div/ Place 6.7,„ ,/ / N
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition / /D�Z6/Q Place of Disposition Cc�
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2
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) / (lot number) (grave number)
0 Name of Se on or Person in Charge of Premises tL11 E L. c z.i 1
Z (please print /
Signatur kw, V- i�(,( Titl
(over)
DOH-1555(02/2004)