Voorhis, Nancy 1
NEW YORK STATE DEPARTMENT OF HEALTH 4 3I11
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nancy G Voorhis Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/14/2014 82 years War or Dates
IF4 Place of Death Hospital, Institution or
Z City, TowR iIMIXXX Glens Falls Street Address Glens Falls Hospital
0 Manner of Death Er4tural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Ili
Circumstances Investigation
W Medical Certifier Name Title
d James North M D
Address
100 Broad Street Glens falls, N Y 12801
Death Certificate Filed District Number Register Number
City, TowXXXXIIMXXX Glens Falls 5601 231
❑Burial Date Cemetery or Crematory
❑Entombment 05/16/2014 Pine View Crematorium
Address
., [ Cpemation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2❑and/or Address 1
-, Hold
ta
0 Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
Q 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
Name of Funeral Firm Making Disposition or to Whom
Oi Remains are Shipped, If Other than Above
Address
CC
',' Permission is hereby granted to dispose of the human remains described above ass indicated.
Digi Date Issued 05/16/2014 Registrar of Vital Statistics LO C) Jp'.9. W
(signatur
District Number 5601 Place Glens Falls
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
u Date of Disposition 4--11"Il1 Place of Disposition , actr„......
(address)
Link
VI
CC (section) ti (lotnum (grave number)
ci Name of Sexton or Person in Charge of Premises �L- +H;
z (please print)
1.____
Signature4 Title 01
(over)
DOH-1555 (02/2004)