McGavisk, Rita C .kC)EP
NEW YORK STATE DEPARTMENT OF HEALTH1.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rita C. McGavisk Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 20,2017 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls,NY Street Address Glens Falls Hospital
Manner of Death ' I Natural Cause Accident ❑Homicide ❑Suicide n Undetermined n Pending
Circumstances Investigation
i; Medical Certifier Name Title
CI Dr Cunningham,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number,
City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
❑EntombmentDecember 22,2017 Pine View Crematory
Address
®Cremation Queensbury,NY
Date Place Removed
zO ❑Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
, Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
1W.
1. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued p2l 2 21 I 7 Registrar of Vital Statistics W(am+-AQ_
(si ature)
District Number 560 t Place 6 \\ S V
I certify that the remains of the decedent identified above were disposed of in accordance/_ with this permit on:
W Date of Disposition )-LizyI Place of Disposition pry]toreui Gce 0-z ..tr/-y
W (address)
U)
O (section) (lott number) (grave number)
p• Name of Sexton or Person in Ch rge of Premises Ju )IC., 694-rrz ect.,Lte
Z (please print)
w Signature — Title (please
z,
(over)
DOH-1555(02/2004)