Siuda, Ora NEW YORK STATE DEPARTMENT OF HEALTH r Of
Vital Records Section 4.. Burial - Transit Permit
Name First Middle Last Sex
-' Ora Siuda Female
Date of Death Age If Veteran of U.S. Armed Forces,
' October 24, 2013 99 War or Dates
,,, Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address The Stanton Nursing& Rehab Center
Manner of Death n n n Undetermined Pending
x Natural Cause Accident Homicide Suicide
Circumstances Investigation
Alik Medical Certifier Name Title
,L, Suzanne Blood MD
Address
'` ; Carey Rd.,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 ( Li (0
❑Burial Date Cemetery or Crematory
October 25, 2013 Pine View Crematorium
El Entombment Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
N
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
E
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
`i 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
Permission is hereby granted to dispose of the human remains described above as indicated.
' Date Issued \Old laa3Registrar of Vital Statistics C, c c`
(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
iu Date of Disposition 10 h i°13 Place of Disposition ,,,6(�=,1.., �,.cip r--
(address)
W
Cl)
CL (section) (lot umber) (grave number)
pName of Sexton or Person i harge of Pr mises 4,,14 +- ,Spnn/�
Z (plehse print)
W Signature 4111— Title t;1Ziry* m Q.
(over)
DOH-1555(02/2004)