Cifone, Roberta NEW YORK STATE DEPARTMENT OF HEALTH 70
Vital Records Section Burial - Transit Permit
r:N Name First Middle Last Sex
-. Roberta W.
:r Cifone Female
0 Date of Death Age If Veteran of U.S. Armed Forces,
•�:* November 13, 2014 92 War or Dates
` : Place of Death Hospital, Institution or
' . City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
n, Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
,: Circumstances Investigation
: Medical Certifier Name Title
Daniel Larson
°':ti Address
▪ 9 Carey Road,Queeensbury,NY 12804
`: : Death Certificate Filed District Number Regis lumber
: City, Town or Village Fort Edward 5755 ((�1
❑Burial Date Cemetery or Crematory
III Entombment November 14, 2014 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
i Hold
Cl)
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:7:; 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
IRemains are Shipped, If Other than Above
Address
: r
;:::: Permission is hereby granted to dispose of the huma r ins describedagove a indicated.
' t• i" (1 JV
;:;; Date Issued 1 ����� Registrar of Vital Statistics
s, (signature)
:: District Number 5755 Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ill Date of Disposition /i in fri Place of Disposition ,Z(J„,� ( c 1ar ..
Ill (address)
V
0 (section) i (lot number,_- (grave number)
ZName of Sexton or Person in Charge of Premises Gt j}. �a
W ((Please print)
Signature 4,.. _4,...� Title G�RECI .
(over)
DOH-1555(02/2004)