Mainville, Elizabeth M. NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Elizabeth M.Mainville Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/14/2020 89 Years War or Dates
�. Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
WW Manner of Death Undetermined Pending
0 Natural Cause �Accident �Homicide �Suicide
V Circumstances Investigation
W Medical Certifier Name Title
Wendy Steinhacker PA
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 70
❑Burial Date Cemetery,Crematory or Facility Name
04/16/2020 Pine View Crematory
Entombment Address
X❑Cremation Queensbury,New York
❑Donation
0 ❑Removal Date Place Removed
and/or and/or Held
N
Hold Address
Q
IL Date Point of
<A ❑Transportation
p by Common Shipment
Carrier Destination
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 Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
}— Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/16/2020 Registrar of Vital Statistics CaroCtnex�(egarde 0-4er(EYectrorticallySrgned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition N 111 Place of Disposition
(address)
W
N (section) (lot in?um (grave number)
Q
Name of Sexton or Person in Charge joremises .� '�A
z ease print/
W Signature Z Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) - ` 1
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on b=jpernmnit
Official Funeral Directors Reg.or License#