Sarsalari, Lisa 4511
NEW YORK TAT,F.,,IDEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
.''' Name First Middle Last Sex
Lisa W., Sarsalari Female
- Date of Death Age If Veteran of U.S. Armed Forces,
a' December 13, 2015 54 War or Dates
"f' Place of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause n Accident ❑Homicide I I Suicide n Undetermined ❑Pending
Circumstances Investigation
:? Medical Certifier Name Title
Charles Yun Dr.
Address
102 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number / Register ber
City, Town or Village / ��/
❑Burial Date Cemetery or Crematory
December 15,2015 Pine View Crematory
❑Entombment Address
E Cremation Quaker Road, Queensbury, New York 12804
Date Place Removed
ZZ 71❑Removal and/or Held
and/or Address
H Hold
N
o Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
" Permit Issued to g
Re istration 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 hereb granted to dispose of the human remains de cribed a ve as indi•-ted.
Date Issued / / l`j f Registrar of Vital Statistics a-p4„, di. co
(signature)
District Number 6,6 ' Place
I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
Z
W Date of Disposition 1 Z.-/7-/r- Place of Disposition 2 h e v rep..' G/e-mc,1eri
2 (addressf
W
Cl)
0 (section) ` /t (lot number) (grave number)
pName of Sexton or Person in Charge of Premises J k ra,i bG rn tea/e
Z (please print)
W
Signature Title Gfe.na.1'y 4-S�:;S/14-n.�
(over)
DOH-1555(02/2004)