Whittemore, Helne rI � ti1
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Helen Beatrice Whittemore Female
Date of Death Age If Veteran of U.S. Armed Forces,
-; February 2, 2015 93 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Queensbury, NY Street Address Stanton Nursing& Rehab Centre
Manner of Death I 1 Natural Cause Accident n Homicide Suicide Undetermined I 1 Pending
Circumstances Investigation
' Medical Certifier Name Title
Suzanne Blood,MD
> ; Address
,
Queensbury,NY
Death Certificate Filed District Number Register Number
`:1 City, Town or Village Town of Queensbury,NY 5657 (Cl
❑Burial Date Cemetery or Crematory
February 5, 2015 Pine View Crematorium
El Entombment Address
❑X Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Iri I Removal and/or Held
and/or Address
F' Hold
(4)
0 Date Point of
O. ❑Transportation Shipment
'p 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
4, 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
fr% Permission is hereby granted to dispose of the human r aits de - • a•o as i icated.
<,
Date Issued —�KRegistrar of Vital Statistics l _R Oct,
z' (signet e
District Number 5657 Place Town of Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 7-- S'1( Place of Disposition jK V./ Li-r44'.
(address)
W
N
CC (section) 4,00,,Sot number) (grave number)
pName of Sexton or Person in Charge of Premises �t�wNt
Z te
/ (please print)
WSignature �AtJ Title ilLE*t'r(M-
(over)
DOH-1555(02/2004)