Woodbury, Mary NEW YVJ?K SATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Elizabeth Woodbury Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 28, 2015 97 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death X Natural Cause n Accident n Homicide Suicide Undetermined Pending
UCircumstances Investigation
W; Medical Certifier/ ` �( h C I ta\J L Title
o I
Address
( cLa
Death Certificate Filed > District Number Register Number
City, Town or Village Glens Falls, NY 5601 �j 2-5
❑Burial Date Cemetery or Crematory
December 31, 2015 Pine View Crematorium
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
W
Q Date Point of
n Transportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment
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
I-- Remains are Shipped, If Other than Above
• Address
OL
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued (,2i }j Registrar of Vital Statistics
(signature)
District Number 5 6 0 ` Place 6 (Q,\r, s \c 1, l S ),/c-t / age/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition /-4/-/6 Place of Disposition /^//e ecrJ re.y,4aAwry'
2 (address)
N
(section) (lo number) (grave number)
pName of Sexton or Person in Charge of Premises �rr 1 vL/ Z. fa'.1.vt 4,tk
Z g /��/x✓7�'v�F (please print)
W ` C r2 rIa
Signature - Title r
(over)
DOH-1555(02/2004)