Boothby, Alice s i VI 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alice M. Boothby Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 15,2013 88 War or Dates
Place of Death Hospital, Institution or
• Ci ,Town or Villa a Glens Falls Street Address The Pines At Glens Falls
Manner of Death❑Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined 0 Pending
Circumstances Investigation
0• Medical Certifier Name Title
Bernard Villajuan
Address
161 Carey Rd,Queensbury,NY 12804
Death Certificate Filed District Number Register i umber
City, Town or Village Glens Falls 5601 l��J
❑Burial Date Cemetery or Crematory
November 20,2013 Pine View Crematorium
0 Entombment Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
G ri Removal and/or Held
and/or Address
Hold
to
O Date Point of
gi 0 Transportation Shipment
as by Common Destination
Carrier
El 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
-• Remains are Shipped, If Other than Above
Address
Permission is h ebYgranted to dispose of the human r mains escribe above as dica ed.
Date Issued Registrar of Vital Statistics 47 A 4
(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:
Z Z (�t� Ot,_
W Date of Disposition N-1o�i'3 Place of Disposition ,,na atl
(address)
W
fY
(section)
4 /`(lot number) (grave number)
pName of Sexton or Person in Charge of Premises 1,kri �t''�vr
Z (plea print)
W Signature Tide 62 weal
(over)
DOH-1555(02/2004)