Fish, Grace s
NEW YORK STATE DEPARTMENT OF HEALTH #
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Grace Fish Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 9, 2014 83 War or Dates
Place of Death Hospital, Institution or
2 City, Town or Village Glens Falls Street Address 40 Harrison Ave
pManner of Death ' Natural Cause Accident n Homicide ( I Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
Ci Robert Love,MD
Address
3 Irongate Center, Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 ! `j
❑Burial Date Cemetery or Crematory
January 10, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z
U Removal and/or Held
and/or Address
H Hold
O Date Point of
as ❑Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
• Address
Ui
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued / 1 0 ` / -/ Registrar of Vital Statistics c��,�,.�Q-
(signature)
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:
H
W Date of Disposition i/3 i+1M Place of Disposition •(InU a4 Cate-.-
(address)
W
co
re (section) (lot number (grave number)
Q Name of Sexton or Person in Charge of Premises .�� �r44.14-
Z {lease prin
W Title CIQ, �n1�cQA�
Signature �...
(over)
DOH-1555(02/2004)