Hughes, Edith if
NEW YORK STATE DEPARTMENT OF HEALTH " '''' /t 14(S Vital Records Section Burial - Transit Permit
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Name First Middle Last Sex
Edith Hughes Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 23,2013 90 War or Dates
I., Place of Death Hospital, Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
O Manner of Death Natural Cause Ej Accident EI Homicide El Suicide r7Undetermined ri Pending
W Circumstances Investigation
O Medical Certifier Name Title
O Michael Fuller
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Registgr�umber
City,Town or Village Glens Falls 5601 Z3 11
❑Burial Date Cemetery or Crematory
Entombment July 24,2013 Pine View Cemetery
Address
®Cremation Quaker Road, Queensbury,,NY 12804
Date Place Removed
z ni Removal and/or Held
• and/or Address
E. Hold
N
O Date Point of
N D Transportation Shipment
p by Common Destination
_ Carrier
EDisinterment Date Cemetery Address
Renterment Date Cemetery Address
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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
i- Remains are Shipped, If Other than Above
2 Address
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a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued _1 1 23/13 Registrar of Vital Statistics Oki
(signatu )
District Number 5601 Place Glens Falls) IV y
I certify that the remains of the decedent identified above were disposed of in accordancet with this permit on:
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W Date of Disposition �-ZS'-l?S Place of Disposition 2c V,tee fv.,i +'�ctOrv�-�-
2 (address)
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rt (section) d
(lot number) C (grave number)
0 Name of Sexton or Person in Charge of remises . c ," v r"'E
Z ( se pant)
W Signature Title C17M4TZ
(over)
DOH-1555(02/2004)
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