Fiore, Marilyn � 5
NEW YORK STATE DEPARTMENT Cf HEALTH
Vital Records Section Burial - Transit Permit
_; Name First Middle Last Sex
MarilynFiore Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/21/2019 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 10 Marine Dr.
Manner of Death FX�Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Robert Evans,MD
Address
Glens Falls,NY
Death Certificate Filed Distri t Numb r Register Number
.' City, Town or Village Moreau
❑Burial Date Cemetery or Crematory
❑Entombment December 24,2019 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZC ❑Removal and/or Held
and/or Address ,
Hold
QDate Point of
y ❑Transportation Shipment
p by Common Destination
Carrier _
❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
eau Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r desl'j a Ive as indicated.
3 Date Issued a d / Registrar of Vital Statistics
(s' ature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Lu Date of Disposition I?,- 'Zy-/Q Place of Disposition ?n,�,
(address)
W
N
(section) (lot number)// (grave number)
pName of Sexto r r on in Charge of Premises �1"Ilr.,M �G�✓rr �C.� �-
Z (pie se print) )
W Title 1_.e =
Signature
(over)
DOH-1555(0212004)
Public Health Law Sec. 4145(2b) 013180
Receipt
Human remains of delivered on , 20—
PinaView Cemetery Representing the funeral home named on burial permit
4cial Funeral Directors Reg.or License#