Lee, Sandra 01/11/2018 11:39 5183773446 LIGHTS FUNERAL HOME PAGE 01/01
NEW YORK STATE DEPARTMENT OF HEALTH 4 ; vty
Vital Records Section BurialTransit Permit
.sis, - ter► _/ -
-44 Name First Middle Last Sex
,;4 SANDRA LEE NICOLE HERMANCE FEMALE
4 Date•of Death • Age If Veteran of U.S.Armed Forces,
e, 01/08/2018 30 War or Dates — -
for Place of Death Hospital,Institution
City,,,Town or Villas- City of Albany V or Street Address ST. MARGARETS CENTER
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+ril _ cause lJ ""uu „ ,_, L`fidOh? �--+ li'mli
dit Medical Certifier Name Title
MARIA KANSAS DEVINE MD
Ix : Address
r 314 SO MANNING BLVD.ALBANY NY 12208
Beath Certificate Filed District Number Register Number
i City,Town or Village City of Albany 101 _ 0084
tom
❑Burial Date Cemetery or Crematory
❑ Burial nt 01/16/2018 PINE VIEW CREMATORY •
Cremation Address
QUEENSBURY_,-NY
Date Place Removed .
1-1 Removal rand/or Held
and/or
h- Hold Address
til
ty Transportation Date Point of
G 3 ❑ By Common Shipment
p, Carrier Destination
El Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued To Registration Number
' ' Name of Funeral Home SINGLETON SULLIVAN POTTER FUNERAL HOME 01598
may\ I
''`. Address
407 BAY ROAD, QUEENSBURY, NY 12804
"y.. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
PPermission is hereby granted to dispose of the human remains described above as indicated.
01/11/2018
'` Date Registrar of Vital Statistics ` Cs
f'' Issued
' (signature)
c
:
', District Number 101 Place City of Albany, NY
' I certify that the remains of the decedent identified above were disposed of in accordancecop with this permit on:
Date of Disposition I/!7 l i$_ Place of Disposition 1 r.c tJ_i (,t."
1 (address)
ui
:e
o (section) (lot number) (grave number)
:v Name of Sexton or Person In Charge of Premise - ,Ii j v 441(
r, (please print) it
Signature �( Title API'VDt
(over)
DOH-1555(02/2004)