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Gorman, Shirley E .� s /od7 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Shirley E.Gorman Female Date of Death Age If Veteran of U.S.Armed Forces, 11/26/2021 97 Years War or Dates • Place of Death Hospital,Institution or WCity,Town or Village Kingsbury Town Street Address 54 Ninth Avenue H,Kingsbury Town, New York 12839 • Manner of Death ❑X Natural Cause 0 Accident Ei Homicide ❑Suicide ❑Undetermined Pending W ✓ Circumstances Investigation WG Medical Certifier Name Title Alexis Mondella NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Kingsbury Town 5762 P3 ElBurial Date Cemetery,Crematory or Facility Name 11/29/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury,New York Donation 0 ❑Removal Date Place Removed and/or and/or Held F- Hold Address 0 a Date Point of N ❑Transportation p 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 }- Remains are Shipped,If Other than Above 2 Address CC W a" Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/29/2021 Registrar of Vital Statistics CyntliaA Bard1n(EYectronicaf Signed) (signature) District Number 5762 Place Kingsbury 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 ��-�.�pz/ Place of Disposition U ` Ae U/tLo4) e/-,yff ry 2 (address) W (section) (lot/numbe (grave number) O Name of Sexton or Person in Cha of Pr mi ,A7J f'19t7/v,� Lf/o0 please print/ W Signature Title © '1- (- DOH-1555(07/18)p 1 of 2 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#