Germond, Tina NEW YORK STATE DEPARTMENT OF HEALTH, N
Vital Records Section .. Burial - Transit Permit
•
' Name First Middle Last Sex
Tina Christine Germond 1 Female _
Date of Death Age If Veteran of U.S. Armed Forces,
August 20, 2012 56 War or Dates No
Place of Death Hospital, Institution or
Z. City, Town or Village Glens Falls Street Address 158 Bay St.
tu
ri Manner of Death I XI Natural Cause I I Accident Homicide Suicide Undetermined Pending
US Circumstances Investigation
W Medical Certifier Name Title
0 John P. Stoutenburg Dr.
Address
Glens Falls Hosp,Glens Falls,NY 12801
Death Certificate Filed District Number Register
City, Town or Village Glens Falls 5601 SiS
❑Burial Date Cemetery or Crematory
Entombment August 22, 2012 Pine View Crematorium —
Address
El Cremation 21 Quaker Road, Queensbury, NY 12804
Date 1 Place Removed
Z I I Removal ! I and/or Held
O and/or Address
H Hold
to
O Date Point of
NTransportation Shipment
6 by Common Destination
Carrier
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
- Remains are Shipped, If Other than Above
2 Address
CC
Q.
Permission is her by granted to dispose of the human r ains de cribed ab&`e as indicate
Date Issued g egistrar of Vital Statistics 277 ___e_r, 2- 2is-e
(signature)
District Number 5601 Place Glens Falls / /(47 1 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z //�` L�
LU Date of Disposition t-2�-i2 Place of Disposition gr4OtcS1 (ten•-'W(t�
2 (address)
UJ
U)
OC (section) y4/ (lotmumber) (grave number)
Op Name of Sexton or Person in Charge of Premises a' ' f Spw �y
Z
(pl se print)
W Signature L_ Title C(t ,4 4-7(y fL
(over)
DOH-1555(02/2004)