Fuller, Florence NEW YORK STATE DEPARTMENT OF HEALTH _ It
Vital Records Section Burial - Transit Permit
-, Name First Middle Last Sex
Florence E. Fuller Female
::? Date of Death Age If Veteran of U.S. Armed Forces,
August 8, 2011 96 War or Dates No
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 34 Herald Dr.
Manner of Death 0 Natural Cause n Accident 0 Homicide ❑Suicide ri Undetermined n Pending
Circumstances Investigation
g Medical Certifier Name Title
P' T Coppens
Address
3 Irongate,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
iiiii City, Town or Village Queensbury 5657 .72
❑Burial Date Cemetery or Crematory
August 9,2011 Pine View Crematorium
D Entombment Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
1' Hold
N
0 Date Point of
N Li Transportation Shipment
a by Common Destination
Carrier
E
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Sullivan Minahan& Potter 01646
Address
407 Bay Road, Queensbury,NY 12804
=s, Name of Funeral Firm Making Disposition or to Whom
k� Remains are Shipped, If Other than Above
S Address
1'
G Permission is hereby granted to dispose of the human re ins described ve as indicated.
Date Issued Q-..0 Registrar of Vital Statistics 0
ii (sig ture)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition $ 1i- ( Place of Disposition RA ciAd iaaN.,-
W (address)
(I)
W (section) i(lot number (grave number)
QName of Sexton or Pers in Charge of remises t,, h� .A
'Z (please print)
Signature i Title C�%tti1:c J
(over)
DOH-1555(02/2004)