Hersh, Evelyn It 3c3
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
!:;igi Name First Middle Last Sex
Evel Hersh Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 2, 2017 96 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 10 Forest Lane
Manner of Death n Natural Cause n Accident ❑Homicide I I Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Gerard Abess MD
EV Address
Glens Falls,NY
ill Death Certificate Filed District Number Register Number
11 City, Town or Village Queensbury, NY 5657 --)
❑Burial Date Cemetery or Crematory
❑Entombment May 4,2017 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
F_ Hold
co
O Date Point of
NElTransportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
n
Reinterment Date Cemetery Address
j. Permit Issued to Registration Number
Name of Funeral Home Sin leton Sullivan Potter Funeral Home 01596
dii Address
407 Ba Road o ueensbur NY 12804
Name of Funeral Firm Making Disposition or to Whom
,:
Remains are Shipped, If Other than Above
4 Address
611
si Permission is herby granted to dispose of the human remains describe bove as indicated.
:: Date Issued `t. aot Registrar of Vital Statistics -I �.._.q
(signature)
::: District Number�(Dc Place (') � O.( Q LA-ea-TN .
I certify that the remains of the decedent identified above were disposed of in accord:nce wit this permit on:
uui Date of Disposition A 16 0 Place of Disposition f3ssnekiv--1 ' ri:v{L-
W` (address)
CO
O (section) Alot number) r (grave number)
Z• Name of Sexton or Person in Char of Premises ',s e i 411
(plea a print)
W6
Signature Title (01=r jVL
(over)
DOH-1555(02/2004)