DeAvila, Barbra Jean r' .t
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Pe emit
Bureau of Vital Records
Name First Middle Last Sex
:,§ Barbra Jean deAvila Female
Date of Death Age If Veteran of U.S.Armed Forces,
`' 01/16/2023 59 Years War or Dates
i Place of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death I �
Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
., William Cleaver MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
' ,Town or Village 5601 31
Burial Date Cemetery,Crematory or Facility Name
,`f 01/18/2023 Pine View Crematory
Entombment Address
E1Cremation Queensbury,New York
z
Donation
Removal Date Place Removed
_'Ill
and/or Held
and/or
/ Hold Address
Date Point of
Transportation Shipment
by Common
Carrier Destination
Disinterment
Date Cemetery Address
e Date Cemetery Address
Reinterment
XI Permit Issued to Registration Number
- Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Z Name of Funeral Firm Making Disposition or to Whom
_ Remains are Shipped,If Other than Above
Address
-' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/18/2023 Registrar of Vital Statistics Megan Nol'n(ECectronicaCCy Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11111 7 3 Place of Disposition .--7 (L
(address)
(section) plot number/ (grave number)
Name of Sexton or Person in Charge of Pre i h/ tv L Svvv4 it
E. /p/ea print/
g
Si nature Title (1714,711H 174
DOH-1555(o7/18)p 1 of 2 l
C21, 6606
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#