Lacombe, Marilyn NEW YORK STATE DEPARTMENT OF HEALTH ' b I
Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
Marilyn Lacombe Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 3, 2017 82 War or Dates
},, Place of Death Hospital, Institution or
ACity, Town or Village Queensbury Street Address Warren Center
p Manner of Death ❑X Natural Cause n Accident Homicide Suicide n Undetermined Pending
1U Circumstances Investigation
lij Medical Certifier Name Title
Roslyn Socolof,MD
Address
Queensbury,NY
Death Certificate Filed District Number ter Number
City, Town or Village Queensbury, NY 5657
❑Burial Date Cemetery or Crematory
May 8, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z El Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IX
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E Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issue r)- 1 Registrar of Vital Statistics f _ c G6/1.0�._
(signature)
District Number `) Place ) d �, V I (D uti29 4
I certify that the remains of the decedent identified above were disposed of in ac ordanc with this permit on:
Z I
W Date of Disposition 5 19I n Place of Disposition fioe ,J `slw eeiw
2 (address)
W
U)
(section) // (lot number) `- (grave number)
it
p Name of Sexton or Person in Charge of Premises ��ir �.�{�r. �• J��+�t
Z IN (p/base print)
Signature Title (4 1lefWC.
(over)
DOH-1555(02/2004)