Burt, Alberta NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
i Alberta Ann Burt Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/02/2018 70 Years War or Dates
,``°.ki Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Rayeski DO
a Address
>; 100 Park St,Glens Falls,New York 12801
w Death Certificate Filed District Number Register Number
ai
:�- City, Town or Village Glens Falls 5601 474
'®Burial Date Cemetery or Crematory
10/09/2018 St.Alphonsus Cemetery
❑Entombment Address
❑Cremation Queensbury, New York
Date Place Removed
Z
Removal and/or Held
mand/or Address
O
Hold
.D Date Point of
❑Transportation Shipment
aby Common Destination
Carrier
El Disinterment
Date Cemetery Address
❑Reinterment Date Cemetery Address
as Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home l 01596
Address
,u 407 Bay Rd,Queensbury,New York 12804
"° Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
11
Permission is hereby granted to dispose of the human remains described above as indicated.
ei. Date Issued 10/03/2018 Registrar of Vital Statistics Robert Curtis(ECectronicalrySigned)
(signature)
. District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
/�
W� Date of Disposition /(�'/ 1/8 Place of Disposition s�-• A ! >ns r� a � Ai
(address) �}
Cl,
C r1 -
i'z (section) lot n ber) (grave number)
0\
I Name of Sext or Person in Charge of Premises I1iv� d 3,...
z // (please print)
Signature (/ Title
(over)
DOH-1555(02/2004)