Round, Mary NEW YORK STATE DEPARTMENT OF HEALTH /may V)11.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Louise Round Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 2, 2015 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Death 12_ Natural Cause Accident Homicide Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Rayeski,DO
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
`5t�
City, Town or Village 67 J
❑Burial Date Cemetery or Crematory
12/4/2015 Pine View Crematory
❑Entombment Address
❑x Cremation 51 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
F' Hold
N
0 Date Point of
Nn 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
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12. 3))5 Registrar of Vital Statistics (.f VCJI✓L4 Y`Sc. Lk
(signature)
District Number 5 k 1 Place 6 -S FQ t \5 Al 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1.) %'- I5 Place of Disposition gle v�,e�� Cre_n.�4vr4'LJ�
2 (address)
W
co
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises 1 „h 04-1,y ' t , /le°
W Y,4 ®L I (Please print)
Signature ��„�. Title CremaJor�, _04"
(over)
DOH-1555(02/2004)