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Demboski, Marguerite F t R (� NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Marguerite F Demboski Female Date of Death Age If Veteran of U.S.Armed Forces, 10/23/2023 91 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 17 Hughes Court,Queensbury Town, New York 12804 `p Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title 0 David Cunningham MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 160 Burial Date Cemetery,Crematory or Facility Name 10/25/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation ❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 a Date Point of V)❑Transportation Q by Common Shipment Carrier Destination 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 I— Remains are Shipped,If Other than Above a Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/24/2023 Registrar of Vital Statistics Caroline 7fi(fegardeBarber(E(ectronica1CySigned) (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: IF- Z Date of Disposition 10I4173 Place of Disposition ridi.,+2E4.1 Pak-*VI WILTA) IJJ 2 (address) W OC Q (section) 4 (lot number) (grave number) g Name of Sexton or Person in Cha f Premises A ev 6 tt — Z (Tease print) W Signature Title �i�Fi►�11u1 fl7Z DOH-1555(07/18)p 1 of 2 L • CI 1 7 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#