Dutra, Elsie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elsie Alice Dutra Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 28, 2012 85 War or Dates
Place of Death Hospital, Institution or
.Z City, Town or Village Queensbury Street Address 268 Big Boom Road
0: Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
LILI Circumstances Investigation
us Medical Certifier Name Title
O. e7 / j)
Address P�.A.- 2 ?e )//
Death Certificate Filed District Number I Register Number
City, Town or Village Queensbury 5657 I
❑Burial Date Cemetery or Crematory
November 29, 2012 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
N
0 Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment 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
wI:*+ Remains are Shipped, If Other than Above
'SS• Address
IX.
ASS
" ': Permission is here y granted to dispose of the human remains described aboate as indicated.
Date Issuec�� la-Sic ' Registrar of Vital Statistics >C..__ '"ti
/� �---___
(signature)
p ;1 District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition//d log-Place of Disposition I 'n/LA/i, e< C400
2 (address)
W
N
re (section) Z t nu ber) (grave number)
O stlit
ca Name of Sexton Pe son i rge of Premises ' �,iJ
W '' (please print)
Signature C /d Title Cm, iv
(over)
DOH-1555(02/2004)