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McCormack, Marjorie G. NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Marjorie G.McCormack Last Sex Date of Death Female Age If Veteran of U.S.Armed Forces, 11/19/2019 84 Years War or Dates F. Place of Death --FHospital,Institution or QZ City,Town or Village Niskayuna Town Street Address Pathways Nursing And Rehabilitation Center Manner of Death ©Natural Cause VAccident Homicide Suicide Undetermined Pending CMedical Certifier Name Title Circumstances Investigation Roman Koldayev MD Address 1805 Providence Ave,Niskayuna Town,New York 12309 Death Certificate Filed District Number City,Town or Village Register Number g Niskayuna 4652 74 Burial Date Cemetery,Crematory or Facility Name 11/25/2019 Pine View Crematory Entombment Address Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed F and/or and/or Held N Hold Address O 4' Date Point of U)❑Transportation C by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Name of Funeral Home Singleton Sullivan Potter Funeral Home Registration Number Address 01596 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom i— Remains are Shipped,If Other than Above Address Q W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/22/2019 Registrar of Vital Statistics Michele 911 Martinet'(ECectronicaCCy Signed) /signature/ District Number 4652 Place Niskayuna, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition y_/ Place of Disposition V,c,� C r, „�, W (address) N 8 (section) (lotnumber) (grave number/ Name of Sexton or Person in Cha of Prep Y N '_ z (please print) W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013106 Receipt Human remains of ? delivered on 1 ! , 20 Pine View Cemetery �— Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#