Sullivan, Helen 1- 1 # 91
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ri Name First Middle Last Sex
Helen Sullivan Female
Date of Death Age If Veteran of U.S.Armed Forces,
' 11/11/2018 98 Years War or Dates
it• Place of Death Hospital, Institution or
City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
WManner of Death fi Natural Cause ❑Accident El Homicide 0 Suicide ❑Undetermined ❑Pending
Circumstances Investigation
I Medical Certifier Name Title
Eileen Spinelli NP
, Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 66
❑Burial Date Cemetery or Crematory
1-1 11/13/2018 Pine View Crematory
❑Entombment Address
;3®Cremation Queensbury, New York
Date Place Removed
g ri❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
a by Common Destination
Carrier
`❑Disinterment
Date Cemetery Address
1.4 a❑Reinterment Date Cemetery Address
• Permit Issued to Registration Number
r) Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
=1 Address
407 Bay Rd,Queensbury,New York 12804
XName 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 11/13/2018 Registrar of Vital Statistics Aimee Makoney(ECectronica1TySigned)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�� 4
W Date of Disposition li i 1113 Place of Disposition ? tL- rI fl
ill
(address)
IX (section) ') (lot number) c (grave number)
pName of Sexton or Person ip Charge of F'-emises 1�!'y J e�,��1
z /f`% (pl se print)
W Signature L' Title If2ElY»9 44,
(over)
DOH-1555 (02/2004)