Keller, Barbara r fI?SS
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
P:' Name First Middle Last Sex
Barbara T. Keller Female
O Date of Death Age If Veteran of U.S. Armed Forces,
} October 14, 2015 76 War or Dates
g Place of Death • Hospital, Institution or
City, Town or Village Fort Ann Street Address 75 Hadlock Pond Road
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier
11
Name Title
. Noelle Stevens,MD
:: Address
;;. 100 Broad Street, Glens Falls,NY 12801
;0 Death Certificate Filed District Number Register Number
,•r:: City, Town or Village 575-1-/ 13
❑Burial Date Cemetery or Crematory
❑Entombment October 19, 2015 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or 1.7. Hold
CO
O Date Point of
wTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
s Permit Issued to Registration Number
:::.:4
, 1 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
Remains are Shipped, If Other than Above
Address
r.. Permission is hereby granted to dispose of the human r ains described • •o - as indicated.
1
; i Date Issued INs-- /5 Registrar of Vital Statistics 4 s'!e}+2-6-7
:'r (signature)
r$r District Number 6-9S—� Place -'B�Lt i...it.._ � (2,b'2.7
}rrr
,._.,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /)
w- Date of Disposition /old I15 Place of Disposition gmti L,ftnet0+,,,..
(address)
W'
U)
re (section) n (lot number (grave number)
Q Name of Sexton or Person in Charg jof Premises t.444 SVAPt(
UZ Irtj'ilTlease print)
Signature 4 Title (IV OR(
(over)
DOH-1555(02/2004)