Palmer, Gwendolyn 1 .
NEW YORK STATE DEPARTMENT OF HEALTH W 110
Vital Records Section Burial - Transit Permit
r Name First Middle Last Sex
rx Gwendolyn Lewis Palmer Female
;e.' Date of Death Age If Veteran of U.S. Armed Forces,
:*—�a.e.1 March 29,2015 80 War or Dates
'`Y Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death I X'Natural Cause Accident 1 Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
`1 Dean Reali
r,: Address
i®p 100 Park Street, Glens Falls,NY 12801
• .; Death Certificate Filed District Number Registef N ber
• City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
ID Entombment March 31, 2015 Pine View Crematorium
Address
0 Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
0 ' and/or Address
= Hold
to
O Date Point of
wTransportation Shipment
3 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
r:,` Permit Issued to Registration Number
° Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
;ss, Address
'".s 407 Bay Road, Queensbury, NY 12804
�r Name of Funeral Firm Making Disposition or to Whom
I'� ` Remains are Shipped, If Other than Above
Address
;e;:e; Permission is hereby granted to dispose of the humantremains cribed a• •ve as in icate .
:. O3 .( nlfi 15 Registrar ,,yj / 41
;�,� Date Issued of Vital Statistics
:;•:: si.nature)
iii.,' District Number Place
°r 5601 Glens Falls /IJ y off (
I certify that the remains of the decedent identified above we e disposed of in accordance with this permit on:
Z
W Date of Disposition t{- 1 l.ar Place of Disposition ,,RU,r. 0
W (address)
Ct (section) ,_(lot numbeg (grave number)
Qt Name of Sexton or Person in Charge of Premises t i4„4
Z p/ease print)
tu
Signature - Title CIE Vo/'l1l
(over)
DOH-1555(02/2004)