Dunham, Marjorie .41k it 33)
NEW YORK STATE DEPARTMENT OF HEALTH /Vital Records Section Burial - Transit Permit
'jti, Name First Middle Last Sex
Marjorie A. Dunham Male
e t Date of Death Age If Veteran of U.S. Armed Forces,
Ma 4,2015 94 War or Dates
r,r Place of Death Hospital, Institution or
:1 City, Town or Village Queensbury Street Address 39 Longview Dr.
Manner of Death n Natural Cause I 1 Accident El Homicide Suicide Undetermined Pending
•:_;� Circumstances Investigation
16
Medical Certifier Name Title
h,r Patricia Auer
Address
41 Carey Rd,Queensbury,NY 12804
Death Certificate Filed District Numberregister Number
r: City, Town or Village �-� —7
�.• 9 Queensbury 5657
❑Burial Date Cemetery or Crematory
❑Entombment May 6, 2015 I Pine View Crematorium
Address
El Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
, ;r Permit Issued to Registration Number
:';:; Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
{ Address
0 f 407 Bay Road, Queensbury, NY 12804
:: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tL�
, ., Permission is hereby granted to dispose of the human r mains describedaA f as indicated.
. fl Date Issued�! (4.!�1 C Registrar of Vital Statistics Cti (1-1 -___
��j� (signature)
rt ' District Number Place
;::;; 5657 Queensbury
:.r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition S'Jgjac Place of Disposition % C"4-do.,,
W (address)
U
tX (section) / (lot number4 (grave number)
pName of Sexton or Person in Charge of Premises A *--iival-
Z {please print)
iW 4 Signature , Title irprm,tk,
(over)
DOH-1555(02/2004)