Coviello, Ann J 00b`
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ann J Coviello Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/28/2019 91 Years War or Dates
IN Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
VCircumstances Investigation
GMedical Certifier Name Title
Anthony Petracca MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 560
Burial Date Cemetery,Crematory or Facility Name
12/30/2019 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
Place
z ❑Removal Date Removed
Pand/or and/or Held
N Hold Address
0
'JL Date Point of
40) Transportation
by Common Shipment
Carrier Destination
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
�. Remains are Shipped,If Other than Above
Address
W
I Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/30/2019 Registrar of Vital Statistics !Po6e&,*,ZrewC41rtir(Electronicaf Srgned/
/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:
F-
W Date of Disposition �^2 3/-7 Place of Disposition ty►Q V(�t,t/ r a
M (address)
W
N Q /section/ ((ot�umber/ (grave number/
_
O Name of Sexton or Pers arge of Premises r �� /p(easeprW0,�
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013191
Receipt
Human remains of ~, +� '1 { delivered on R , 20
-10
-* m�View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#�