Pulito, Dolores NEW YORK STATE DEPARTMENT OF HEALTH-- " '" #W
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dolores G. Pulito Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 11, 2015 78 War or Dates
F- Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 72 Cedar Court
LU
a Manner of Death ❑X Natural Cause n Accident n Homicide Suicide ❑Undetermined Pending
W Circumstances Investigation
to Medical Certifier Name Title
O Patricia Auer,PA
Address
Queensbury,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
February 13, 2015 Pine View Crematorium
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
H Hold
u)
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment 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
fe
I
Permission is hereb granted to dispose of the hu an remains desc ' ed above as indicated.
Date Issued ' c Registrar of Vital Statistic q Cu__9.. _
(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
W Date of Disposition Zf flJ)c Place of Disposition frttV iw) et —A
w (address)
co
m (section) 14 r(lot number (grave number)
pName of Sexton or Person in Ch rge of Premises ,� its
Z A,.. please prin)
Signature ).... Title MAN f 1 ,
(over)
DOH-1555(02/2004)