Dempsey, Patricia NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section • e Burial - Transit Permit
''• '7, Name First Middle Last Sex
Patricia Ann Dempsey Female
''' Date of Death Age If Veteran of U.S. Armed Forces,
RA July 19,2012 88 War or Dates
'' Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death u_kiNatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined 1-1 Pending
Circumstances Investigation
• Medical Certifier Name l Title
../ ..fir . I 1 S Ge,( MID1
'"'f I Address v:g DWiLic\SibLAJ\_%\ n‘v gg%
r% ' Death Certificate Filed vL District Number Register Number
€ { City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
❑Entombment July 20,2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z 1-1 Removal and/or Held
and/or Address
Hold
CO
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
,"% Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
:,:l Address
ft' 407 Bay Road,Queensbury,NY 12804
'ii
t Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
. .• Date Issued 7 )2v`/2 _ Registrar of Vital Statistics LA)
(signature)
District Number 5601 Place Glens Falls,NY 12 46 I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1-7,3-a Place of Disposition F,,,u wi rr4-4GI(w
W (address)
N
O (section) —(lot number) (grave number)
QName of Sexton or Person in Char a of Premises aril ,- J.P }-
W --- lease print)
Signature -1- Title a¢Myl-rGn
(over)
DOH-1555(02/2004)