Williams, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
trl Elizabeth Jane Williams Female
Date of Death Age If Veteran of U.S. Armed Forces,
'' October 19, 2016 87 War or Dates
'
�, Place of Death Hospital, Institution or
; City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause n Accident ❑Homicide ❑Suicide n Undetermined ❑Pending
s Circumstances Investigation
Medical Certifier Name Title
Paul Bachman,MD
Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number � I Register Number
i
, Cty, Town or Village i_X�/QJ
❑Burial Date Cemetery or Crematory
❑Entombment October 21, 2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
f Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
A Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,--" Address
0
Permission is hereby granted to dispose of the human remains described above as indicated.
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�r Date Issued 1 U( -2--( / 16 Registrar of Vital Statistics W
4 (sig1n re)
3 District Number 66 O/ Place 6 CQ S rc,1 \S / �v'y
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z -! I r a Oci A_
W Date of Disposition /D r z5�/6 Place of Disposition Stu ,ry
2 (address)
W
'I)
OC (section) /(lot number) (grave number)
Op Name of Sexton or Person in Charge of Premises tiff'�►^ �t.ii,'ll
Z / /� (pl ase print)
W Signature G I .144:T Title Cat/APR-
(over)
DOH-1555(02/2004)