Audette, Kathleen NEW YORK STATE DEPARTMENT OF HEALTH;. v ,,. $ot
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kathleen M. Audette Female
Date of Death Age If Veteran of U.S. Armed Forces,
aM December 24, 2014 _ 67 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address 42 Grove Ave.
Manner of Death L2L Natural Cause Accident Homicide 0 Suicide Undetermined Pending
E. ,.' Circumstances Investigation
1 Medical Certifier Name Title
} Tim Murphy Coroner
Address
VI 100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
IM City, Town or Village Glens Falls 5601 592
`:< ElBurial Date Cemetery or Crematory
December 29, 2014 Pine View Crematorium
iMi 0 Entombment Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
5Removal and/or Held
R❑; and/or
�;,�; Address
0
Hold
Date Point of
ti El Transportation Shipment
C by Common Destination •
mi Carrier
Q Disinterment Date Cemetery Address
iiiIiiiiQ Reinterment Date Cemetery Address
iiii:iiilliiiili Permit Issued to Registration Number
iNi Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
• Address
407 Bay Road, Queensbury, NY 12804
ffl Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
al Address
CC
9:'` Permission is hereby granted to dispose of the human remains des rribedd ab ve a 'cated.
Date Issued Registrar of Vital Statistics 4,E
(signature)
iniii District Number 5601 Place Glens Falls
iv
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition Ifl illy Place of Disposition 'ti,c IL, 60,..,
(address)
141
tin
II (section) lot number) (grave number)
ei Name of Sexton or Person in Charge of Premises 1 Ll 'S 71
2 (please print)
Signature �� Title CIVEN7Oit
(over)
DOH-1555 (02/2004)