Ormstrup, Greta NEW YORK STATE DEPARTMENT OF HEALTH ir
:
Burial - Transit ermit
Vital Records Section
Name First Middle Last Sex
Greta W. Ormstrup Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 19, 2016 107 War or Dates n/a
Place of Death Hospital, Institution or
ZCity, Town or Village Granville Street Address Indian River Nursing Home
0' Manner of Death Undetermined Pending
W.G �Natural Cause n Accident n Homicide Suicide
Circumstances Investigation
w Medical Certifier Name Title
Q`
Address
Death Certificate Filed District Number Registeumber
City, Town or Village Granville, NY 5725hc
❑Burial Date Cemetery or Crematory
April 22, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
E" Hold
O Date Point of
N Transportation Shipment
a by Common Destination
Carrier
n 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
1—, Remains are Shipped, If Other than Above
M Address
w
0.'' Permission is her y granted to dispose of the human re ,;(ns-des•d a e as indicated.
/� x
Date Issued Y' c7Z/ /(v Registrar of Vital Statistics ` — ""
(signature)
District Number 5 7 5 Place ��-� //-r//e /(/,/ 3.?
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition yh51/(, Place of Disposition 2 Ver.' G ..^
Ili
(address)
Cl)
re (section) (lot num ) (grave number)
pName of Sexton or Person in Charge of Pre ises !v✓�
Z
/� (lease print)
• Signature //�! Title rilift"11,1
(over)
DOH-1555(02/2004)