Nolan, Shirley NEW YORK STATE DEPARTMENT OF HEALTH VI
Vital Records Section e _ T. Burial - Transit Permit
Name First Middle Last Sex
Shirley H. Nolan Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 28, 2012 81 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Granville,NY Street Address Orchard Nursing & Rehab Center
Manner of Death n Natural Cause n Accident Homicide 'Suicide n Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
G Brian Kilpatrick,MD
Address
West Pawlet,VT
Death Certificate Filed District Number Register Number
City, Town or Village Granville,NY 575Co LI I
❑Burial Date Cemetery or Crematory
December 31, 2012 Pine View Crematorium
❑Entombment Address
Ex Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
Hold
N
0 Date Point of
n Transportation Shipment
by Common Destination
Carrier
n Disinterment Date Cemetery Address
n 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
F_ Remains are Shipped, If Other than Above
a Address
OC:
Permission is hereby granted to dispose of the human remains described ,�Q above as indicated.
Date Issued /. J c'Ja0i). Registrar of Vital Statistics 444, a ,
`�`�`� j ignature)
$750 � �1
District Number Granville,NV'lace z, j V t L1,- N 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Place of Disposition Pi,�,1),�,,/
2 (address)
co
(section) .(lot number) (grave number)
pp Name of Sexton or Person in Charge of Premises r,,ip kr h art
Obese print)
Signature � Title Mitt,eci0e_
(over)
DOH-1555(02/2004)