Cushing, Judith NEW YORK STATE DEPARTMENT OF HEALTH ?g
Vital Records Section Burial - Transit Permit
•
Name First Middle Last Sex
Judith Cushing Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 15,2013 79 War or Dates
�,. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause Accident 0 Homicide n Suicide 0 Undetermined Pending
Circumstances Investigation
ujuj Medical Certifier Name Title
p Robert W.Sponzo
Address
Cancer Center,102 Park St,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 3 ,,5 9
❑Burial Date Cemetery or Crematory
August 16,2013 Pine View Crematory
Entombment Address
®Cremation Quaker Road, Queeensbury,NY 12804
Date Place Removed
Z
Ell Removal and/or Held
and/or Address
Hold
N
0 Date Point of
y Li Transportation Shipment
`p by Common Destination
Carrier
Disinterment Date Cemetery Address
❑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
H Remains are Shipped, If Other than Above
2 Address
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued s/ 161/3 Registrar of Vital Statistics tIN) C.
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition gill 113 Place of Disposition et Out.) ��+*c4`or,�•s
(address)
in
(section) (lot number) (grave number)
p Name of Sexton or Perso in Charge of remises t tilt( r ynot-
Z (please print)
W Signature .. Title
(over)
DOH-1555(02/2004)