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Davies, Sharon NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Sharon W. Davies Female Date of Death Age If Veteran of U.S. Armed Forces, April 21, 2015 69 War or Dates No F- Place of Death Hospital, Institution or Z City, Town or Village Glens Falls Street Address Glens Falls Hospital ©w Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending ILA Circumstances Investigation w Medical Certifier Name Title 0 Matthew Varughese Address 100 Park St,Glens Falls,NY 12801 Death Certificate Filed District Number RegisterlImber City, Town or Village Glens Falls 5601 q ❑Burial Date Cemetery or Crematory February 24, 2015 Pine View Crematorium ❑Entombment Address ❑x Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed Z C Removal and/or Held O and/or Address H Hold Cl) O Date Point of NI I Transportation Shipment p by Common Destination Carrier E 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 W', 4.. Permission is hereby granted to dispose of the human mains described above as ind' • .. Date Issued 02 A3/,p/5 Registrar of Vital Statistics ",..3-7 `--) ♦ /�^� (sig ature) District Number 5601 Place Glens Falls — I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition 2114ji6- Place of Disposition Zits.? r. 2 (address) W co O (section) / (lot number) . (grave number) p t• Name of Sexton or Person in Charge of Premises _ #1 t eio* 6 4_, Z (ple se print)• i W Title Signature attiOntif (over) DOH-1555(02/2004)