Joseph, Florence ecii
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
" Name First Middle Last Sex
Florence Alma Joseph Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 12, 2016 106 War or Dates
ti.; .. Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 649 Upper Sherman Ave
Manner of Death �Natural Cause Accident D Homicide pi Suicide Pending
g
1U Circumstances Investigation
at Medical Certifier Name Title
i` David Cunningham,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury, NY 5657 t
❑Burial Date Cemetery or Crematory
December 13, 2016 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
V)
O Date Point of
N ❑Transportation Shipment
as by Common Destination
Carrier
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
Permission is hereby granted to dispose of the human re nl......_
ains described a e as indicated.
Date Issued I A.I k31c0\(0 Registrar of Vital Statistics Mom
(signature)
District Number Place l �___,_ d- C t.-ts_z-r5�
I certify that the remains of the decedent identified above were disposed of in acc danc with this permit on:
Z Disposition3 Pr e I,�j C' C-/�rt 71o,/'
W Date of 2 / /� Place of Disposition r Y� ��
2 (address)
W
Cl)
Ce (section) fOt number) (grave number)
QName of Sexton P in harge of Premises t`i c,✓t CD - a a-. t`'_
Z (please print)
ua Signature Title C r'e r447T
(over)
DOH-1555(02/2004)