Irizarry, Kathleen Ann �'1-2
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kathleen Ann Irizarry Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/19/2019 71 Years War or Dates
Place of Death Hospital,Institution or
W 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
Jeremy Di Bari MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 543
Burial Date Cemetery,Crematory or Facility Name
12/23/2019 Pine View Crematory
Entombment Address
RI Cremation Queensbury,New York
❑Donation
0 Removal Date Place Removed
and/or and/or Held
I—
iA Hold Address
i R I
Transportation Date Point of
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
Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/23/2019 Registrar of Vital Statistics �kpAert,?ndrewClirns(Ekctro)7icad Signed)
(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:
Date of Disposition Place of Disposition ;CcJ ernes 0!
UA UA (addres/
W
(section) (lyt number) (grave number)
D Name of Sexton or Pers n in �arge of Premises (/-�^ I
(please print) l
W Signature w' Title la.i+t
DOH-1555(o7/i8)p 1 of 2
Public Health Law Sec. 4145(2b) 013172
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#