Benz, Elsie Olive NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Elsie Olive Benz I Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/25/2020 100 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
Mannerof Death El Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
fJ
W Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 52
❑Burial Date Cemetery,Crematory or Facility Name
03/25/2020 Pine View Crematory
Entombment Address
0 Cremation Queensbury,New York
❑Donation
Z Removal
Date Place Removed
F and/or and/or Held
�- Hold Address
Date Point of
to❑Transportation Shipment
Ca by Common
Carrier Destination
Disinterment
Date Cemetery Address
IEJReinterment Date Cemetery Address
Permit Issued to Registration Number
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
W
I Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/25/2020 Registrar of Vital Statistics Carolnexlfegarde(Bade-(Ekctroaica!lySigrred)
(signature)
District Number 5657 Place Queensbury, New York
t� I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I
WDate of Disposition - zu7U Place of Disposition Je i e 10
IE /address/ _
N (section) /l t number/ (grave number/
iQ
Name of Sexton or Person in Ch of Pr i s ' , A C'J �' OD
Z lease print/
Signature Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) N, �13 4 6 5
Receipt
1
Human remains of ( delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#