Perry, Marie NEW YORK STATE DEPARTMENT OF HEALTH lir ` I 615'
Vital Records Section Burial - Transit Permit
4:11tiLLI
Name First Middle Last Sex
Marie Aline Perry Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/18/2017 80 j War or Dates No
ZPlace of Death Hospital, Institution
City , Town or Village City of Albany or Street Address Albany Medical Center
W Manner of Death Natural Undetermined Pending
a` is) ❑ Accident El Homicide ❑ Suicide ❑ ❑
VCause Circumstances Investigation
W Medical Certifier Name Title
p John Cagino MD
Address
43 New Scotland Ave. Albany, NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village City of Albany 101 0144
Date Cemetery or Crematory
❑ Burial 01/20/2017 Pine View Crematorium
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
P Hold
N
d Transportation Date Point of
Shipment
_ Carrier
❑ By Common
p Destination
❑ Date Cemetery Address
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, NY 12084
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
1' Address
W'
C- Permission is hereby granted to dispose of the human remains described above as indicated. ,1
Date 01/19/2017 }k � �
Issued Registrar of Vital Statistics
(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 I/1_)t I J Place of Disposition eqt ti.a 6 10(1*-
w (address)
2
w
cn
re (section) (lot number) (grave number)
O
0 /
W Name of Sexton or Person in Charge of Premises y+t4 �M�+l
(please print) 1
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/l Signature W Title CRC Irfr.Pt
(over)
DOH-1555 (02/2004)