Goodrich, Payton Rose ,rg1I
NEW YORK STATE DEPARTMENT OF HEALTH - '+Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Payton Rose Goodrich Female
v Date of Death Age If Veteran of U.S. Armed Forces,
9/22/2021 0 War or Dates
I Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide 1-1 Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Susan Pantano,MD
3 Address
S Death Certificate Filed District Number Register Number /0
:' City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
❑Entombment September 27, 2021 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
y ❑Transportation Shipment
p by Common Destination
Carrier
❑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 Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission isn hereby granted to dispose of the human rem bins descriibe/d�above as indicated.
0, Date Issued q ilq)70Z. wC��I Registrar of Vital Statistics /
ature)
y
District Number Place C1 I1 15 0115 t kV
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ;�
W Date of Disposition ¶1211?, Place of Disposition Roe vi... 4- i
2 (address)
W
CO
te
(section) (lot nu bar) (grave number)
pName of Sexton or Person in Charge of Premises /4As ��^'.�sbt
Z (ple4se print)
W j Title iil � roK
Signature F Y �t
(over)
DOH-1555(02/2004)
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ', delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#'