Edwards, Anne Cormuss r
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vitat Records
Name First Middle Last Sex
Anne Cormuss Edwards Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/01/2020 66 Years War or Dates
r Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
MA Circumstances
of Death Natural Cause Accident Homicide Suicide Undetermined Pending
M Circumstances Investigation
Medical Certifier Name Title
Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number —]—Register Number
City,Town or Village Glens Falls 5601 5
❑Burial Date Cemetery,Crematory or Facility Name
01/03/2020 Pine View Crematory
Entombment Address
ICremation Queensbury,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
gHold Address
❑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
j 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 01/03/2020 Registrar of Vital Statistics RpAertflnrlrewCurtir(EkctronicadSigned)
(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:
ti Date of Disposition ZO Place of Disposition �r�
(address)
W
1N (section) lot number/ (grave number/
Q
Name of Sexton or Person in Charge of Premises r.I L
(plea print/
W Signature al ��Z Title
DO H-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) M
Receipt
4 _
Human remains of delivered on , 20_
s_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#