Dawson, Mary L
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary E Dawson Female
W Date of Death Age If Veteran of U.S.Armed Forces,
f 01/12/2018 84 Years War or Dates
Place of Death Hospital, Institution or
j City,Town or Village Queensbury Town Street Address Westmount Health Facilityz El of Death Natural Cause Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gumey Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 9
®Burial Date Cemetery or Crematory
01/18/2018 Pine View Cemetery
ntarbment Address
❑Cremation Queensbury, New York
Date Place Removed
• Removal and/or Held
T• and/or Address
Hold
Date Point of
= Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
far;
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
• Address
• 407 Bay Rd,Queensbury,New York 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 01/16/2018 Registrar of Vital Statistics Caroline.7(Barber(E(ectronicaaySigned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of t e decedent identified above were disposed of in accordance with this permit on:
aaitoe,Date of Disposition / /g tb1I'Place of Disposition 21iL 4,1t4,"_,142..a_Ati
addre
- (se on) (A number) (grave number)
N:tFZ
or Person in Charge of PremisesUS ' Title
(over)
DOH-1555 (02/2004)