Vanderwarker, Barbara NEW YORK STATE DEPARTMENT OF HEAL-'H I IF 3 5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Barbara J. Vanderwarker Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 18, 2013 89 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 18 Goldfinch Road
p Manner of Death X Natural Cause n Accident n Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
O Patricia Auer
Address
161 Carey Road Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657
❑Burial Date Cemetery or Crematory
January 22, 2013 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
U)
O Date Point of
u) Transportation Shipment
a by Common Destination
Carrier
Ti 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
H Remains are Shipped, If Other than Above
2 Address
CL
O.
Permission is hereby granted to dispose of the human re ains described above s indicated.
Date Issued 1c),=,LIc:XA,aj Registrar of Vital Statistics
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Lu Date of Disposition I-74-t3 Place of Disposition „.:04 LrtActorl,,0...
W (address)
U)
(section) dr:
(lot number) (grave number)
▪ Name of Sexton or Person in Charge of P emises L 3tHw�'
Z (p ase print)
W /
Signature G Title l Pw!d4[-C
(over)
DOH-1555(02/2004)