Hughes, Marjorie NEW YORK STATE DEPARTMENT OF HEALTH L 11
Vital Records Section f Burial - Transit Permit
Name First Middle Last Sex
',' Marjorie B. Hughes Female
li Date of Death Age If Veteran of U.S.Armed Forces,
pfy;
October 4,2014 99 War or Dates
Place of Death Hospital, Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause n Accident Ei Homicide E Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Gamal Khalifa, MD
VA Address
f 100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register N tuber
i City, Town or Village Glens Falls,NY 5601 q 6 t!
❑Burial Date Cemetery or Crematory
October 6,2014 Pine View Crematorium
D Entombment Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
H Hold
CO
p Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
E Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
' Permit Issued to Registration Number
fc Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 1
f.�` Address
• 407 Bay Road, Queensbury,NY 12804
r, Name of Funeral Firm Making Disposition or to Whom
; Remains are Shipped, If Other than Above
Address
N. Permission is hereby granted to dispose of the human remains described above as indicated.
r%r Date Issued 10 1 & / 1 i( Registrar of Vital Statistics LA-) Cal-- -- " 1,.,
(signatu )
fr
• District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Io(1/Il Place of Disposition god Cr, ,=—
2 (address)
W
O (section) d(tot number)Ar� (grave number)
p Name of Sexton or Person in Charge of Premises •1t ��
Z (phase print)
W Signature _____4*__ Title cCl'I tinte
(over)
DOH-1555(02/2004)