Butler, Rosamond , , ,q zac
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
d Name First Middle Last Sex
r Rosamond Butler Female
0� Date of Death Age If Veteran of U.S. Armed Forces,
a March 17, 2016 84 War or Dates NA
Place of Death Hospital, Institution or
City, Town or Village Town Of Queensbury Street Address 20 Amethyst Drive, Queensbury, NY
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
l'a Circumstances Investigation
A.e. Medical Certifier Name Title
ip. David Cunningham,MD
4 Address
3 Irongate Center Glens Falls,NY::r;:; Death Certificate Filed Diktfj�ict 1>I4Arnpr Reg&ter Number
i:: City, Town or Village Town of Queensbury, NY �(� I
❑Burial Date Cemetery or Crematory
March 18, 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
F_ Hold
N
O Date Point of
Wn Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
r Permit Issued to Registration Number
::r:: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
;f:;r Address
1 407 Bay Road, Queensbury, NY 12804
▪ Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above _
Address
:...i Permission is hereby granted to dispose of the human emains describe bove as indicated.
..*K:
Date Issued � �.�l ZS� l 1p Registrar of Vital Statistics
�� (signature)
District NumberS"�1/4.yoTh Place ) p v_._, Cy( C2 LA_.2 ,... b
I certify that the remains of the decedent identified above were disposed of in a, orda ce with this permit on:
Z
W Date of Disposition 31z1'16 Place of Disposition &View (wMator -
W (address)
U)
CC (section) (lot number).., (grave number)
p r,Name of Sexton or Person in Charge of Premises if J&r+it-
W �(Cr lease print)
Signature 441Title (RAM a/
(over)
DOH-1555(02/2004)