Sharp, Helen �'' # lin
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
f%- Name First Middle Last;z, Sex
r = Helen Sharp Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 19,2016 102 War or Dates n/a
Place of Death Hospital, Institution or
❑
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death n Natural Cause Accident Homicide Suicide ❑Undetermined n Pending
r Circumstances Investigation
lit Medical Certifier Name Title
t
..'' Address
0
Death Certificate Filed District Number Reais) ,r ti,umber
City, Town or Village Fort Edward,NY 5755 t i
❑Burial Date Cemetery or Crematory
February 23, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
OZ ❑Removal and/or Held
and/or Address
�" Hold
Cl)
O Date Point of
N ❑Transportation Shipment
a by Common Destination
_ Carrier
Li Disinterment Date Cemetery Address
❑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
1
Permission is ereby granted to dispose of the humane ins de,scrib d b ve as 'ndicated.
Date Issued�. a0 Registrar of Vital Statistics V
(signature)
District Number 6165Place -07,07t f 6
k, g
I certify that the remains of the decedent identified above were disposed of in accordancel with this permit on:
ILI Date of Disposition Z/Z3//b Place of Disposition ILVt4J r+4tor, .
W (address)
N
CL
0 (section) A (lot number. (grave number)
p Name of Sexton or Person in Charge of Premises fist Ijr )Imat
Z ( lease print)
W Signature la�D
1-040t— Title fatli T
(over)
DOH-1555(02/2004)