McCoy, Harriet NEW YORK STATE DEPARTMENT OF HEALTH 3(')
Vital Records Section Burial - Transit Permit
- Name First Middle Last Sex
Harriet Eva McCoy Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 18, 2012 82 War or Dates
• Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Stanton Nursing& Rehab Centre
444'a Manner of Death 0 Natural Cause 0 Accident D Homicide n Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Dr Roslyn Socolof,MD
Address
Glens Falls,NY 12801
Death Certificate Filed Queensbury,NY District Number Re sterNumber
City, Town or Village 5657
❑Burial Date Cemetery or Crematory
❑Entombment June 19,2012 Pine View Crematorium
Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ri Removal and/or Held
G and/or Address
H Hold
N
0 Date Point of
N OTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment 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
w
Permission is hereby granted to dispose of the human r mains described bove ads indicated.
• Date Issued L9 1 1 1 934:3 Registrar of Vital Statistics c C • nA-t..._,
s (signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�Z DispositionPlace of Disposition /�
Date of lo�to��'L p �(,�eUu.✓ Cep-�"arty�
W (address)
CO
re (section) (lot numpr) (grave number)
0 Name of Sexton or Person in Charge of Premises ��r Liertit
IZ (please print)
Signature Title Cot tuccalt,
(over)
DOH-1555(02/2004)