McAuliffe, Christina co 71V
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
+�� Name First Middle Last Sex
Christina McAuliffe Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 16, 2015 64 War or Dates NA
Place of Death Hospital, Institution or
City, Town or Village North Creek Street Address Adirondack Tri County Nursing Home
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Jas F. Hindson MD
Address
x� 112 Ski Bowl Rd. North Creek, NY 1245 3
Death Certificate Filed District Nu bes Registe Number
''r City, Town or Village 5
�. 9 Town of Johnsburg � `�_ �0
❑Burial Date Cemetery or Crematory
December 18, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
W
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
g Permit Issued to Registration Number
r� Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
•4 Address
;{ 407 Bay Road, Queensbury, NY 12804
r; ' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
0" Permission is hereby granted to dispose of the human re 'ns de ribed bove as ii c ed.
.:.s
'ti; Date Issued )2'" lg' )� Registrar of Vital Statistics
:.;} (signature)
'''. District Number 64 Place `� S 10,
O.
I certify that the remains of the decedent identified above werllisposed of in accordance with this permit on:
W Date of Disposition /2-)-/j Place of Disposition pine i/,"eU /24r1 sey
W (address
U)
IX (section) (lot number)/ (grave number)
Q Name of Sexton or P rson in Charge of Premises J L.f,�,i t '4is?4t-4.e
'Z (please print)
Signature ��� Title G./�esei G-f'D ,—
(over)
DOH-1555(02/2004)