Shea, Mary NEW YORK STATE DEPARTMENT OF HEALTH -4
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Rita Shea Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 15,2014 83 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of DeathuiL1771Natural Cause 111 Accident El Homicide 0 Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Daniel Larson,MD
;' Address
Fort Edward,NY
Death Certificate Filed District Number Register Number
: City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
III Entombment July 16, 2014 Pine View Crematory
Address
®Cremation Queensbury, NY
Date Place Removed
ZO ri❑Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
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
Permission is hereby grant d to dispose of the humaremain escrii�ed above - indi -ted.
Date Issued Q (p Registrar of Vital Statistics /Z( --, Q�
signature)
F District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above re disposed of in accordance with this permit on:
W Date of Disposition - -)1-1'4 Place of Disposition ,rail{.✓ �1*-t tw
2
LU (address)
V)
pC (section) - (lot num (grave number)
Name of Sexton or Perso in Char a of Premises �,4r1. n
Z (please print)
Signature _ Title 0240
(over)
DOH-1555(02/2004)