Healy, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH i Tr,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elizabeth Agnes Healy Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 11, 2015 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death R Natural Cause Accident Homicide
Name Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier1 Title
,r Daniel Way,MD
: Address
Fier Glens Falls,NY
r Death Certificate Filed District Number Register jVyq r
l City, Town or Village Glens Falls,NY 5601 / 7`
❑Burial Date Cemetery or Crematory
April 13, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
Fitand/or Address
H Hold
tO
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
.°s,$ 407 Bay Road,Queensbury, NY 12804
:e
.•. Name of Funeral Firm Making Disposition or to Whom
I j ReRemains are Shipped, If Other than Above
Address
1 Permission is herebygranted to dispose of the human remains described above as indicated.
p
ig, LA)
:.s Date Issued � 1 13 j J, Registrar of Vital Statistics
,•:.•
::"r (signature)
_; District Number 5601 Place Glens Falls,NY /° z/
FI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition A/I Tilc Place of Disposition .R;*4V,,,i ( -,j ,•--
W (address)
Cl)
Q (section)
g a A (lot nu r (grave number)
Name of Sexton or Person in Char a of Premises `"
Z I (please print)
W
Signature Title /IX oni? ._
(over)
DOH-1555(02/2004)