Cohen, Rachel NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rachel Leah Cohen Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 15 2017 38 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 16 Empire Avenue
Manner of Death ❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Sikiirica
Address
f 1340 State Route 9 Lake George,NY 12845
`l Death Certificate Filed District Number __[_Register Number `7, 0
City, Town or Village Glens Falls 5601
❑X Burial Date Cemetery or Crematory
❑Entombment January 17 2017 Shaaray Tefila
Address
❑Cremation Media Drive, Queensbury, NY 12804
Date Place Removed
OZ 1-1 Removaland/or Held
0 and/or Address
Hold
N
aDate Point of
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 1L Registrar of Vital Statistics
(signat re)
District Number 5601 Place Glens Falk, �j U
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
gDate of Disposition /7 Place of Disposition ,rhrrq t�i day �a�
W (address)
N
(section) (lot number) (grave number)
Q Name of Sexton or Person in Charg of Premises `�o ��,�• � s 2
Z (please print)
W
Signature Title
(over)
DOH-1555(02/2004)