Gilsenan, Sarah 7.3/
NEW YORK STATE DEPARTMENT-C; HEALTH Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
Sarah Teresa Gilsenan Female
Date of Death Age If Veteran of U.S. Armed Forces,
aO",
ctober 6,2016 88 War or Dates
r'; Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause 0 Accident E Homicide n Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier
5
IName Title
Kelly Krill,PA
Address
I. 100 Park Street,Glens Falls,NY 12801
iDeath Certificate Filed District Number I Register Number Di ge
; City, Town or Village
❑Burial Date Cemetery or Crematory
El Entombment October 7, 2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
O
and/or Address
I-- Hold
N
O Date Point of
N ['Transportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Sind,leton Sullivan Potter Funeral Home 01596
, Address
." ) 407 Bay Road, Queensbu y, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i'
r.. Permission is hereby granted to dispose of the human remains described above as indicated.
"Date Issued �� I 2C registrar of Vital Statistics r���v�2 ��
f
f r,r (signature)
f District Number 5 6 p/ Place 6 (�,Spok \\ S 3 iv y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition /p z/j Place of Disposition ?Fr/e Ca y e./e41464-0 f
2 ! (addressj
W
(I)
re (section) `` (lot number) (grave number)
pName of Sexton or rson in C iarge of Premises �-J v / ;a e, 6a 4-4 e
Z (please print)
W Signature a Title Gr�"e74.71v . ".
(over)
DOH-1555(02/2004)