DeLong, Elizabeth .. i, 471Z
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elizabeth I. DeLong Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 23,2013 96 War or Dates
I... Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 532 Ridge Road
pManner of Death 0 Natural Cause Accident Homicide 0 Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Glen Anderson
Address
9 Carey Rd,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 1 5657 1.
El Burial Date Cemetery or Crematory
El Entombment Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
z
ri Removal and/or Held
and/or Address
F" Hold
N
O Date Point off
Transportation Shipm nt
p by Common Destination
Carrier
E]Disinterment Date Cemet ry Address
El Reinterment Date Cemetery Address
Permit Issued to i 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
IX
w
aPermission is hereby granted to dispose of the human emains described above as indicated.
Date Issued 1 l �.(9 '� egistrar of Vital Statistics C A---.— Q. �li-L�
(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 /�'
Date of Disposition Ii-Zl'0Place of Disposition O +a.) t_rese"loft
W (address)
CO
rt (section) /tisit n ber) /� (grave number)
pName of Sexton or Person/harge of Premises `/ rat 'midi
Z (pie se print)
W Signature IL Title C2aiMD} L
(over)
DOH-1555(02/2004)