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Delong, Judith NEW YORK STATE DEPARTMENT OF HEALTH ; 4Cf3I Vital Records Section 1. v,n Burial - Transit Permit , Name First Middle Last Sex fil Judith I. Delong Female Date of Death Age If Veteran of U.S. Armed Forces, 10 July 29,2013 55 War or Dates ''l Place of Death Hospital, Institution or City,Town or Village Queensbury Street Address 532 Ridge Road Manner of Death uikNatural Cause n Accident ❑Homicide ri Suicide El Undetermined n Pending Circumstances Investigation Medical Certifier Name Title t,,,, Dr Gillani,MD AAddress %� Glens Falls NY 12804 Death Certificate Filed District Number I egjsier Number City, Town or Village Town of Queensbury,NY 5657 `j ❑Burial Date Cemetery or Crematory ❑Entombment July 31,2013 Pine View Crematorium Address ©Cremation Quaker Road, Queensbury,NY 12804 Date Place Removed Z ❑Removal and/or Held and/or Address H Hold 0 Date Point of N ❑Transportation Shipment p by Common Destination Carrier Ei Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 IlAddress ,,:, 407 Bay Road, Queensbury, NY 12804 M1.7Name 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. OV, Date Issued 11,311 ]3 Registrar of Vital Statistics C\_— ti � ibrL -� (signature) "; District Number 5657 Place Town of Queensbury,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 41ZI1� Place of Disposition - _,. Zv Cifn►Slo{,,,r, W (address) N CC (section) (lot number) (grave number) pName of Sexton or Perso in Charge o Premises ;� ,r .p+rdt Z (ple&se print) W Signature L �� Title L1CLEO Q (over) DOH-1555(02/2004)