Grimes, Rachelle NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
::: Name First Middle Last Sex
r Rachelle Lynette Grimes Female
Date of Death Age If Veteran of U.S. Armed Forces,
0 February 8,2018 43 War or Dates N/A
,' Place of Death Hospital, Institution or
City, Town or Village Queensbury,NY Street Address 16 Founders Way
Manner of Death n Natural Cause ❑Accident ❑Homicide n Suicide 1-1 Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
J Terry Comeau. Coroner
Address
Lake George,NY
Death Certificate Filed District Number Register Number
44
City, Town or Village Queensbury,NY 5657 0
❑Burial Date Cemetery or Crematory
El Entombment February 20,2018 Pine View Crematory
Address
®Cremation Quaker Road,Queensbury,NY
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
Ell
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
r Address
�,,� 407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Zig Permission is hereby granted to dispose of the human re ains described by a as indicated.
Date Issued I`l�Ll$ Registrar of Vital Statistics C.� a_ , 2�_
(signature)
District Numbe Place nt_g_..1...\ -,0 -c (17 LLQ.9_1.-. _
▪ I certify that the remains of the decedent identified above were disposed of in acc• dance with this permit on:
111• Date of Disposition Z!22 f I$ Place of Disposition 11(1--, c'" --
W (address)
C
W (section) A (lot number) (grave number)
QName of Sexton or Person in Charge of Premises ; Si..st
`iJ
Z ( lease print)
ASignature Title lRr`a+r} ti
(over)
DOH-1555(02/2004)