Gray, Jean NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jean H. Gray Female
Date of Death Age If Veteran of U.S. Armed Forces,
a November 22, 2012 91 War or Dates No
t„ Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Pines At Glens Falls
s; Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Ail Circumstances Investigation
w, Medical Certifier Name Title
0 Bernardo R.Villajuan Dr.
Address
88 Broad St,Glens Falls,NY 12804
Death Certificate Filed District Number Register Number
' City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
November 26, 2012 Pine View Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
O Date Point of
u) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
i 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
E Address
re
:a3
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 4)) 2 3/1 - Registrar of Vital Statistics L3 Gt-..r-rsz. UJJtif
(signa re)
District Number 5601 Place Glens Falls s (U
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ii iiidi2 Place of Disposition ROW 14 G dit.-_
2 (address)
W
U)
A4:1c1L—
(lot )� (grave number)
(section) numberp Name of Sexton or Person in Charge of Premisesv�W (please print)
Signature L Title CzeMA60/
(over)
DOH-1555(02/2004)