McDonald, Kay NEW YORK STATE DEPARTMENT OF HEALTH t # 3 Z.
Vital Records Section Burial - Transit Permit
,%: Name First Middle Last Sex
:rr: Kay Pauline McDonald Female
Date of Death Age If Veteran of U.S. Armed Forces,
':*: May 9, 2016
82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 8 Grouse Circle
g Manner of Death X Natural Cause I 'Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Po f 1 c 1 Ci Ru es, Title ryi 9
:: Address
31 Le) �C1,rc kd 0 cn f um f Iwt f a \2 0k4
Death Certificate Filed District Number Register Number
ti tir City, Town or Village
LI Burial Date Cemetery or Crematory
El Entombment May 10, 2016 Pine View Crematorium
Address
❑X Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F' Hold
U)
0 Date Point of
yTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'§:.ii Permit Issued to Registration Number
i ::; Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
ii:i:iAddress
407 Bay Road, Queensbury, NY 12804
ii?.: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
M Permission is hereby granted to dispose of the human r ma drib b e i cated.
,'' G
Date Issued S—tD—�b Registrar of Vital Statistics
:•{ : (signat
District Number 5161 Place c -----'-..
I certify that the remains of the decedent identified ab v were disposed o in ccordance with this permit on:
tu Date of Disposition 5/i t I fN Place of Disposition 4LL1, (address)
W
CO
CC (section) dr..jip.,
.(lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises "1
W (pse print
Signature a /�1�� Title 4,0104
(over)
DOH-1555(02/2004)