Cox, Anne NEW YORK STATE DEPARTMENT OF HEALTH ' 4 it 71
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anne Catherine Cox Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 8, 2015 66 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 1260 West Mountain Road Apt 309
• Manner of Death X Natural Cause Accident n Homicide n Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Q Christopher Hoy,MD
Address
Queensbury,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
January 13,2015 Pine View Crematorium
❑Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
H Hold
N
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n 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
I— Remains are Shipped, If Other than Above
a Address
a
Permission is hereby granted to dispose of the human re described v indic ted.
Date Issued I t a- ;apt. Registrar of Vital Statistics u _.Q GL,,FG
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Lu• Date of Disposition ( //sli5- Place of Disposition
(address)
W
N
(section) lot number) (grave number)
Q Name of Sexton or Per on in Charge of Premises br, t. 31,44v
Z (ple�se print)
Signature Title r121i1 Z
(over)
DOH-1555(02/2004)