Dempster, Lillian 0 3)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
rl.- Name First Middle Last Sex
.51 Lillian A.Dempster Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/16/2018 100 Years War or Dates
Place of Death Hospital, Institution or
3, City, Town or Village Guilderland Town Street Address Our Lady Of Mercy Life Center
Manner of Death Le Natural Cause Accident LII Homicide El Suicide El Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Kathleen Patterson NP
Address
2 Mercycare Ln,Guilderland Town,New York 12084
Death Certificate Filed District Number Register Number
City, Town or Village Guilderland 0155 65
❑Burial Date Cemetery or Crematory
04/20/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
—
Date Place Removed
❑Removal
and/or and/or Held
Address
Hold
Date Point of
3. ❑Transportation Shipment
by Common Destination
Carrier
Date CemeteryAddress
g� Disinterment
€`` — Date Cemetery Address
" ❑Reinterment
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 _
Ti
Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued 04/18/2018 Registrar of Vital Statistics Jean,Jarrett Caddo(ECectronicafySigned)
(signature)
District Number 0155 Place Guilderland, New York
I certify that the remains of the decedent identified above were disposed of in accordancewith this permit on:
p ei�) III DispositionS l
• Date of Disposition Place of ,r, , vs.%,
(address)
(section) 4(lot numbe1) (grave number)
4 Name of Sexton or Person in Charge of Pr miser CCCr(lr•,�PL. 4'40-
z (pl se print)
Ui Signature Title fir "111'
(over)
DOH-1555(02/2004)