Howard, Audrey NEW YORK STATE DEPARTMENT OF HEALTH —, A 41 i gr
Vital Records Section Burial - Transit Permit
-$%' Name First Middle Last Sex
< Audrey Joan Howard Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 11, 2015 84 War or Dates n/a
1, Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 12 Western Ave
0, Manner of Death ❑X Natural Cause n Accident ❑Homicide 1-1 SuicideUndetermined n Pending
Circumstances Investigation
JAI Medical Certifier Name Title
gt, Christopher Hoy,MD
Address
. ;r Queensbury,NY
Death Certificate Filed Town of Queensbury,NY District Number Register Number
a City, Town or Village 5657 L{
❑Burial Date Cemetery or Crematory
March 12, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z
II Removal and/or Held
and/or Address
E Hold
N
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
pi 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
Remains are Shipped, If Other than Above
Address
f
Permission is hereby granted to dispose of the human re ai s describedal�booveeas indicated.
Date Issued 3) 1c}/ O/ Registrar of Vital Statistics et >/���
(signature)
District Number 5657 Place Town of Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Disposition �1 Place of Disposition ', , l p
W Date of Midis- P � ..� � d �-
2 (address)
W
Cl)
Ce (section) Ao°t numbe (grave number)
QName of Sexton or Person in Charge of Premises Ato iiw i
Z (pleate print)
W
Signature IL
Yo__, Title dastifith
(over)
DOH-1555(02/2004)