McIntire, Rita A ft -4
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NEW YORK STATE DEPARTMENT OF HEALTH r Burial - Transit Permit
Bureau of Vital Records
Name First Last Sex
Rita A McIntire Female
Date of Death Age If J.S.Armed Forces,
09/02/2022 80 Years {, ,s
F- Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 2352 Ridge Road,Queensbury Town, New York 12804
p Manner of Death III Natural Cause DA III Homicide uSuicide Fpndetermined Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
a Darci Gaiotti-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number 1 Register Number
City,Town or Village 5657 125
Burial Date Cemetery,( )ry or Facility Name
09/06/2022 Pine View tory
IllEntombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removec
and/or and/or Held
F- Hold Address
N
0
a Date Point of
(I)❑Transportation Shipment
p by Common
Carrier Destination
O
Disinterment
Date Cemetery Address
El
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
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/06/2022 Registrar of Vital Statistics Caroline 7-Ci°arde Barber(ECectronicallySigned)
(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:
Z Date of Disposition ci I$1 ZZ Place of Disposition T 'u Vr_ 67912---
111 (address)
W
N (section) (tot number) (grave number)
CC
ti
G Name of Sexton or Person in C e of Premises /' h. �'�
(pie .e print)
W Signature Title L O W
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#