Zabriskie, Irene NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit ermit
�;;; Name First Middle Last Sex
Ar. Irene Margaret Zabriskie Female
wg Date of Death Age If Veteran of U.S. Armed Forces,
`f July 6, 2016 83 War or Dates
f. Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death C Natural Cause 0 Accident 0 Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
John P.Stoutenburg Dr.
,,,7; Address
'r"{ Glens Falls Hosp, 100 Park St.,Glens Falls,NY 12801
' . Death Certificate Filed District Number Register Number
, ft
%5' City, Town or Village Glens Falls 5601 3 Li 2,
❑Burial Date Cemetery or Crematory
July 8, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ri Removal and/or Held
and/or Address
N Hold
N
0 Date Point of
y El Transportation Shipment
p by Common Destination
Carrier
[j Disinterment Date Cemetery Address
E
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
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
4 1'
,..,,52: Date Issued 7 1 g)20I 6 Registrar of Vital Statistics W CA.t,y,-. Ad"
cw
IY --�� (signs ure)
_yf District Number "��b t Place �, c �A� ` kS 41f ./
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition '? f I l IL Place of Disposition gat,UL... ?
i C p4-,
W (address)
co
CL (section) (I t number (grave number)
pName of Sexton or Person in Charge of Premises 1ni
Z lease print)
W /Signature a` Title CC(t.,1 lirZ.
(over)
DOH-1555(02/2004)