McCoy, Lila 4 1 r5-6 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
.r j Lila J. McCoy Female
Date of Death Age If Veteran of U.S. Armed Forces,
.?. September 15,2014 84 War or Dates
.'.'� Place of Death Hospital, Institution or
City, Town or Village Schuylerville Street Address Stanton Nursing & Rehab Centre
tiManner of Death Natural Cause Accident I 1 Homicide Suicide Undetermined Pending
�f Circumstances Investigation
Medical Certifier Name Title
124, Roslyn Socolof
NY
Address
Stanton NH, 152 Sherman Ave,Glens Falls,NY 12804
i'r: Death Certificate Filed District Number Register Number
City, Town or Village Town of Queensbury 5657 ( I I
El Burial Date Cemetery or Crematory
September 16, 2014 Pine View Crematorium
❑Entombment Address
ElCremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z 1 I Removal and/or Held
and/or Address
�' Hold
N
O Date Point of
O.
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
::▪sr Permit Issued to Registration Number
::: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
N: Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I* Remains are Shipped, If Other than Above
Address
�: Permission is hereb granted to dispose of the human emains described abovr aas indicated.
, '
::; / �L: Date Issued (, Registrar of Vital Statistics c. (/ .. (L,u-__
(signature)
▪ District Number 5657 Place Town of Queensbury
I certify that the remains of the decedent identified above wer isposed of in accordance with this permit on:
w Date of Disposition 9-/9-/t/ Place of Disposition /40. �rlr t_' c _ir;iii �a,./
W (address)
Cl)
(section) number (grave number)
Op Name of Sexto •rJso4Zrge of Premises t G K�//��
w (Pleas print)Signature ` .I 41 Title L --)..--
(over)
DOH-1555(02/2004)