Boldman, Theresa M. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Perit03
Bureau of Vital Records '
Name First Middle Last Sex
Theresa M Boldman Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/10/2020 84 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Northumberland Town Street Address 4855 Route 50, Northumberland Town, New York 12831
p Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 William Parker MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Northumberland Town 4563 15
❑Burial Date Cemetery,Crematory or Facility Name
11/12/2020 Pine View Crematory
0 Entombment Address
ElCremation Queensbury Town,New York
Donation
Z ❑Removal Date Place Removed
and/or and/or Held
F.
inHold Address
0
Q. Date Point of
Cl) ❑Transportation Shipment
5 by Common
Carrier Destination
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 Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
IH Remains are Shipped,If Other than Above
2 Address
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/12/2020 Registrar of Vital Statistics Denise I) Murphy(Electronically Signed)
(signature)
District Number 4563 Place Northumberland Town, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition nip I Zo Place of Disposition '1 '�I�•� �✓Td f��---
W (address)
W
M (section) (lot numb (grave number)
Name of Sexton or Person in Cha of Premises .+-- ly Ovi44�II.
L ,, (p! se print)
W Signature — Title l 'l(1�1t
DOH-1555(07/18)p 1 of 2
1
t
Public Health Law Sec. 4145(2b) 0-1-4 194
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
i