Engroff, Ruth NEW YORK STATE DEPARTMENT OF HEALTH N' # 3J3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ruth M. Engroff Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 29,2014 93 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Town of Moreau, NY Street Address Home Of The Good Shepard
Manner of Death Natural Cause ❑Accident ❑Homicide n Suicide ❑Undetermined l i Pending
Circumstances Investigation
Medical Certifier
1:
Name Title
., Glen Anderson,PA
Address
k Queensbury,NY _
Death Certificate Filed District Number Register Number
City Village Town or Villa a Town of Moreau,NY 4562 1❑Burial Date Cemetery or Crematory
June 2, 2014 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
E Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
;: Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
o'er Address
</ 407 Bay Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
`.r Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ins described above as indicated.
r
M Date Issued 5130 i j t4 Registrar of Vital Statistics 7)1 _ a Lo tAtui-
9 (signature)
�� �� District Number 4562 Place Town of Moreau,NY
fir t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition (0/3 j,y Place of Disposition �%n war Ci-me/torii_..
W (address)
CA
i, (section) (lot numbe (grave number)p Name of Sexton or Perso in Charge of Premises .mot Ipnni "
W 1L(please print)
Signature t 4 Title CMS(
(over)
DOH-1555(02/2004)