Hope, Hazel 0 S3
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
,'f Hazel Sadie Hope Female
':? Date of Death Age If Veteran of U.S. Armed Forces,
;< October 15,2014 89 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury, NY Street Address 110 Robert Gardens Apt 1
Manner of Death a Natural Cause Accident Homicide n Suicide n Undetermined n Pending
i
Circumstances Investigation
Medical Certifier Name Title
Dr Stratton,MD
Address
10 Queensbury,NY
..G.yi Death Certificate Filed District Number Register Number
'��:%f
1 f City, Town or Village Queensbury,NY 5657 13 (
0 Burial Date Cemetery or Crematory
October 17,2014 Pine View Crematorium
El Entombment Address
0 Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
CC
O Date Point of
g5 ❑Transportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
a Permit Issued to Registration Number
r. Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
' Address
rp,9 407 Bay Road,Queensbury, NY 12804
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 r m ' s de-. ', - •. a,ov, •s i dicated.
\ ►
" Date Issued in--1(07 1iRegistrar of Vital Statistics
r (signet
:4,
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition Pin Place of Disposition ,,,c(L Cow tori
(address)
W
U)
CL (section) (lot number} (grave number)
QName of Sexton or Person in Charge of Premises d,,t L tor
Z (Pease print)
W Signature c ll— Title Cnttittil4-
(over)
DOH-1555(02/2004)