Ingalls-Mark, Gwen R
NEW YORK STATE DEPARTMENT OF HEALTH 4 Soil
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gwen C. Ingalls Mark Female
`: Date of Death Age If Veteran of U.S. Armed Forces,
December 25, 2014 68 War or Dates No
} Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined Pending
Natural Cause n Accident n Homicide n Suicide
Circumstances Investigation
Medical Certifier Name Title
o Shahid Ahmed
Address
100 Park Street, Glens Falls,NY 12801
Death Certificate Filed District Number Register Number z
>% City, Town or Village Glens Falls 5601
El Burial Date Cemetery or Crematory
December 29 2014 Pine View Crematorium
❑Entombment Address ,
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
N• ame of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
4• 07 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
itk
, Permission is hereby granted to dispose of the human remains described� � � above as indicated.
Date Issued 12j aG ) / Registrar of Vital Statistics W��,,p�`'�
(si nature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition IL43:Ily Place of Disposition ,,, CJ 6ei,r
2 (address)
W
CO
(section) /(lot number), (grave number)
O Name of Sexton or Person in Charge of Premises L/ if)
le—
/ (plebse print) 441
w Signature �t, Title Clieult,
(over)
DOH-1555(02/2004)