Burnham, Ruth NEW YORK STATE DEPARTMENT OF HEALTH q•"13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ruth Cardone- Burnham Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 12, 2012 83 War or Dates
1, Place of Death Hospital, Institution or
City, Town or Village Schuylerville Street Address Stanton Nursing& Rehab Centre
Manner of Death Undetermined Pending
Natural Cause n Accident ❑Homicide ❑Suicide
Circumstances Investigation
rti Medical ce,rtifier Name Title
Pr-4-c--\c_c� U V`e-f
Address
QAmy'` r\c\k6
' Death Certificate Filed �J 1 District Number R gi t r Number
City, Town or Village Queensbury,NY 5657 1 I Lp
❑Burial Date Cemetery or Crematory
❑Entombment September 13, 2012 Pine View Crematorium
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
z ❑Removal and/or Held
2 and/or Address
H Hold
N
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment 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
Remains are Shipped, If Other than Above
Address
ill
Di' Permission is ereb granted to dispose of the human r mins described a ve as indicated.
Date Issued is t, II Registrar of Vital Statistics 0, ILti
(signature)
District Number 5657 Place Queensbury,NY 1 a`d 01
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ct- n-it Place of Disposition VI ni Om) p(ivo,
W (address)
Cl)
W (section) 3 ,(lot number) c" (grave number)
Op Name of Sexton or Person in Charge of remises i Em -
Z ( lease print)
W ikiSignature 4— Title0113.Tr
(over)
DOH-1555(02/2004)