Miller, Irene 0!/11I2018 14:20 5183773446 LIGHTS FUNERAL HOME PAGE 01/01
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit 1 S611
Vital Records Section
TIMOTHYi Name First Middle Last Sex
,,,,': Date of Death • Age If Veteran of U.S.Armed Forces,
.-.. Place of Death . Hospital,Institution
' ' C' Town-oc-Village Albany or Street Address ALBANY MEDICAL CENTER
Pt
. , Manner of Death pp! Natural Undetermined n • Pending
El Accident Li Homicide n Suicide LI
ic-N Cause Circumstances I-I Investigation
r "` MARTIN
I
43 NEW SCOTLAND AVE ALBANY NY 12208
e eatCertificate Filed• - District Number Register Number -
-'' City,Town or Village City of Albany 101 1514
❑Bursa! Date Cemetery or Crematory
0 Entombment 07/12/2018 PINE VIEW CREMATORIUM
Address
Cremation QUEENSBURY, NY
Date Place Removed
Removal andlor Held
'2 ❑ and/or -Address
r Hold - - - -
- -_ -
Date Point of
4L Transportation Shipment
IA; E] By Common Destination
,A. Carrier .
0 Date Cemetery Address
Disinterment
Date Cemetery Address
❑ Reinterment
: Permit Issued To Registration Number
4?'I Name of Funeral Home SINGLETON SULLIVAN POTTER FUNERAL HOME 01596
Address --
407 BAY RD.,.QUEENSBURY, NY 12804
is Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,b Other than Above
• Address
u4 Permission is hereby granted to dispose of the human remains described above as indicated.
07/11/2018 ��1�
,441 Registrar of,Vital Statistics
g (signature)
; District Number 101 Place City of Albany, NY .
I certify that the remains of the decedent identified above were disposed.of in accordance with this permit on: •
z Date of Disposition 1)13 k$ Place of Disposition f,Kki... Ar40,,,
' (address)
at
co
Lk (section) (lot nu er) (grave number)
0
= Name of Sexton-or Person in Charge of Premises cpL St.nAt t
(pleaseEU
4.... ) uuls
Signature a Title itkL.
•
(bver)
DOH-1555(0212004) -