Wurzberger, Glayds it 2 (13
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Gladys Wurzberger Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/02/2021 82 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address 7 Birchfield Drive,Queensbury Town, New York 12804
p Manner of Death xi NaturalCause El Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
w Medical Certifier Name Title
O Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 60
ElBurial Date Cemetery,Crematory or Facility Name
03/03/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury,New York
ElDonation
Z❑Removal Date Place Removed. •
and/or and/or Held
H Hold Address
N
0
CI. Date Point of
to ❑Transportation
a by Common Shipment
Carrier Destination
EIDisinterment 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
t Remains are Shipped,If Other than Above
Address
WI
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/03/2021 Registrar of Vital Statistics Caroline Mfiffegarde cBar6er(Electronically Signed)
(signature)
District Number .5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II•-
Z Date of Disposition 3-6 —202(Place of Disposition Pi rJe- tls ew ere-oleicri
(address)
W
N
CC (section) (lot number)]
(grave number)
SName of Sexton or Person in Charge o remise 01/07or'b IC- (please De Gt
W ` �'�'Vtvc� Print/
Signature
X� Title O
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 14609
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Receipt
Human remains of "delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Dir- -•..or License#