Corliss, Consuella NEW YORK STA;TE C?e 'ARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
„,; Consuella J. Corliss Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 11,2015 87 War or Dates
i Place of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Death ❑X Natural Cause ❑Accident n Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Kyle S.Leonard Dr.
Address
} 161 Carey Road,Queensbury,NY 12804
;, Death Certificate Filed Distri mbber Registe N m r
f : City, Town or Village DpOt
❑Burial Date Cemetery or Crematory
December 14, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F' Hold
N
O Date Point of
e) Transportation Shipment
'p by Common Destination
Carrier
u Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
rn 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
iRemains are Shipped, If Other than Above
Address
Permission is hereb granted to dispose of the human emains de cribed above as ind' atec.
Registrar of Vital Statistics -772 d
Date Issued /+� r7/7/. 9 ��
�r% ' r) (signature)
District Number , /) Place ��� `c�6 `//
{f .�' (�=
I certify that the remains of the decedent identified above were disposed of in accordan a with this permit on:
uiDate of Disposition j2,_/6_�6— Place of Disposition J'P,�Q-vr c-N) r✓�'Grnc.for(address)
W
(I)
W (section) /� (lot number) (grave number)
pName of Sexton o Person in Charge of Premises -3, l i‹-v‘ C�a-✓14-a e
W (please print)
Signature Title G rG.n a.oh 7 at.SS;s a,,,
(over)
DOH-1555(02/2004)