Painter, Mildred it 41
NEW YORK STATE DEPARTMP7 OF HEALTH Burial - Transit Permit
Vital Records Section
w
Name First Middle Last Sex
Mildred Valentine Painter Female
Date of Death . Age If Veteran of U.S. Armed Forces,
:::r January 16, 2015 90 War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
ig Manner of Death X Natural Cause Accident- Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
rl Roslyn Socoloff, MD
Address
42 Gurney Lane, Queensbury, NY 12804
Death Certificate Filed Queensbury,NY District Number Register Number
:;r City, Town or Village 5657 ((
❑Burial Date Cemetery or Crematory
January 20, 2015 Pine View Crematorium
❑Entombment Address
❑X Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
U)
O Date Point of
yTransportation 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
r:'i 407 Bay Road, Queensbury, NY 12804
::: Name of Funeral Firm Making Disposition or to Whom
i':'; Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above pas indicated.
Date Issued 1 120l 1 C Registrar of Vital Statistics 4<C( - W-Le� ,-..`
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z '� CP dfo4r.'
W Date of Disposition Jr7oj� Place of Disposition ��: L.
2 (address)
W
CO
CL (section) (lot number (grave number)
Q Name of Sexton or Person in Charge of Premises fps u
Z please print)
ILI
Signature A .,_ Title CiLIii"19 g.
(over)
DOH-1555(02/2004)