Dearstyne, Phyllis C it S-s-
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Phyllis C.Dearstyne Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/14/2022 102 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 18 Kenwood Circle,Queensbury Town,New York 12804
111
`p Manner of Death ❑X Natural Cause Accident ❑Homicide Suicide Undetermined Pending
VCircumstances Investigation
WG Medical Certifier Name Title
Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 119
Burial Date Cemetery,Crematory or Facility Name
08/15/2022 Pine View Crematory
Entombment Address
EICremation Queensbury,New York
Donation
Date Place Removed
0❑Removal
and/or and/or Held
N Hold Address
0
a. Date Point of
fA Transportation
5 by Common Shipment
Carrier Destination
DIDisinterment 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
Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/15/2022 Registrar of Vital Statistics CarolineWildegardC Barber(ECectronicafySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W
Date of Disposition $iIb( 7Z Place of Disposition ,�,�cV'` <>.7f'dr,►�
2 (address)
W
8 (section) A (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ill �to —
/p ase print)
Signature Title aEMl
DOH-1555(07/18)p t 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#