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Dumas, Vivian M
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Vivian M.Dumas Female Date of Death Age If Veteran of U.S.Armed Forces, 01/05/2022 97 Years War or Dates Place of Death Hospital,Institution or ZCity,Town or Village Queensbury Town Street Address 5 Thomas Street,Queensbury Town, New York 12804 p Manner of Death ©Natural Cause ❑Accident ElHomicide ElSuicide ❑Undetermined ❑Pending Circumstances Investigation ILIL1 Medical Certifier Name Title a Sean Campanie NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 2 ©Burial Date Cemetery,Crematory or Facility Name 01/07/2022 Pine View Cemetery ❑Entombment Address ❑Cremation Queensbury,New York ❑Donation Z ❑Removal Date Place Removed Q and/or and/or Held H Hold Address CO 0 D. Date Point of to ❑Transportation 5 by Common Shipment 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 1.- Remains are Shipped,If Other than Above 5 Address IC W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/06/2022 Registrar of Vital Statistics Caroline 2firdegarrfe Barfer(E(ectronicaCCy 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: Z W Date of Disposition • as Place of Disposition a t C)1,uc\y-,e)Q Y.Z QUA'RSDI a C 1 N‘.i. I iit,L4 (address) W Effie ki7 NCC (sects (lot number) (grave number) 8 Name of Sext. r Person in Cha Premises C>«7" ��e , w (please print) 11J Signature K ""`� Title +�\it epC--.+ e_.XZ� DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 012896 Receipt '.�..4 ... ., Human remains of 'y �; delivered on 1 , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# DUMAS NAME Vivian Dumas Age: 97 Lot Owner: Bnnie Gregory Lot# Erie 47D Grave# 2 Case: Concrete Died: 1 .5.2 2 Interred: 1 . 7.2 2 Funeral Home: Regan Denny Stafford Cemetery: Pine View