Sullivan, Edith s' .k
NEW YORK STATE DEPARTMENT OF HEALTH 3D
Vital Records Section Burial - Transit Permit
Name First Middle Last
Sex
Edith Fnda Sullivan Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/10/2018 88 Years War or Dates
Place of Death
Hospital, Institution or
-.rM City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
Manner of Death 0 Natural Cause Accident El Homicide 0 Suicide ri Undetermined ri Pending
Circumstances Li Investigation
'° Medical Certifier Name Title
Kenneth France MD
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed4
District Number Register Number
v• 'it S
City, Town or Village Glens Falls 5601 181
❑Burial Date Cemetery or Crematory
04/11/2018 Pine View Crematory
Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
4❑Removal and/or Held
and/or
, Address
Hold
Date Point of
Q Transportation Shipment
-,-w by Common Destination
Carrierre _
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
lav Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
4 Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
N
: Permission is hereby granted to dispose of the human remains described above as indicated.
5 Date Issued 04/11/2018 Registrar of Vital Statistics WpbertA Curtis(E(ectronicaliySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ill12 118 Place of Disposition 'fat 4 t....
E
(address)
(section) (lot number) (grave number)
' ; Name of Sexton or Person in Charge of Pr ises Iti. .�,^.4f
--a: (pll$ase print)
f Signature 4 -id'-id' Title IE Vg-
(over)
DOH-1555 (02/2004)