Wallace, Ilse NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
ILSE WALLACE Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/02/2021 78 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Granville Village Street Address Granville Center for Rehabilitation and Nursing
p Manner of Death El Natural Cause ❑Accident El Homicide 1=1 Suicide Ei Undetermined Pending
W V Circumstances Investigation
GMedical Certifier Name Title
Shardul Koppar DO
Address
17 Madison St,Granville Village,New York 12832
Death Certificate Filed District Number Register Number
City,Town or Village Granville Village 5725 56
Burial Date Cemetery,Crematory or Facility Name
11/05/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
Donation
8 ❑Removal Date Place Removed
and/or and/or Held
Hold Address
N
0
O. Date Point of
Cl) Li Transportation
O by Common Shipment
Carrier Destination
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
H Remains are Shipped,If Other than Above
a Address
CC
ILL)
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/05/2021 Registrar of Vital Statistics RletiarrlRg6ertr(EYectrortkall:y50e4
(signature)
District Number 5725 Place Granville Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H ,q
W Date of Disposition / /
/f"'ZC9Z/ Place of Disposition e V Q..J (re4n 4IC)
2 (address)
W
N
(section) l /(lot number) (grave number)
8 Name of Sexton or Person in Char of Premis Il)4 y/y/D,✓e //Ovel
Z (please print)
�IL Signature C A Title c�4,' "`i
DOH-1555(07/18)p 1 of 2
0 5302
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#