Hayes, Sandra L 1,...: g 51,21
NEW YORK STATE DEPARTMENT OF HEALTH ` Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Sandra L Hayes Female
Date of Death Age If Veteran of U.S.Armed Forces,.
07/17/2022 70 Years War or Dates
F. Place of Death Hospital,Institution or
WCity,Town or Village Abany Street Address Hudson Park Rehabili�on And Nursing Center
p Manner of Death ❑X Natural Cause Accident ❑Homicide OSuicide ❑Undetermined Pending
UCircumstances Investigation
Medical Certifier Name Title
C Micrarn Jafd MD
Address
325 Northern Blvd,Abany,New York 12204
Death Certificate Filed city ofAlbany District Number Register Number
Village'g 0101 1659
Burial Date Cemetery.Crematory or Facility Name
AddreZ022 Pine View Crematory
Entombment Address
MCremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
a Hold Address
n
Transportation Datey:::1
Point of
by Common Shipment
Carrier Destination
Date Cemetery Address
aDisinterment
Date Cemetery Address
�Reintennent
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
I. Remains are Shipped,If Other than Above
S Address
CC
W
a.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/18/2022 Registrar of Vital Statistics DaltieZS fpfa(Eralarm a16,Stinrd)
(signehire)
District Number 0101 Place city cm Amy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZW Date of Disposition 1 i II it Place of Disposition r•��d�)
2 (address)
W
t7)
lc (section) (lot nnmberlsiti,ii (gra►r number/
8 Name of Sexton or Person in Charge of Premi / CII
~�. tr
/LI
W (P/eaePniM/
Signature Title «�
DOH-1555(o7/18)p t of 2
• F 7
Public Health Law Sec. 4145(2b)
Receipt 3.11,41741 141q.
Human remains of- delivered on , 20 1Z
Pine View Cemetery Representing the funeral home named on burial'permit
Official Funeral Directors Reg.or License#