Shepard, Patti Ann � Igo
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Patti Ann Shepard Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/29/2020 61 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Queensbury Town Street Address 9 Susan Place,Queensbury Town,New York 12804
d Manner of Death Natural Cause Accident 11Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Charles Yun MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 34
Burial Date Cemetery,Crematory or Facility Name
03/03/2020 Pine View Crematory
Entombment Address
0 Cremation Queensbury,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
~N Hold Address
O
d Date Point of
to �Transportation
5 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
} Remains are Shipped,If Other than Above
Address
Q
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/02/2020 Registrar of Vital Statistics CaroCnexklegarde Barder(Ekctronicay Signed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3/3 17o Place of Disposition t
W (address/
W
N umber)
Q
SName of Sexton or Person in Charge of Premi es (section/ (lot n (grave number)
zprint/
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0-13 3
Receipt
Human remains of .j delivered on , 20
Pine View Cemetery Representing the funeral home named on burial per-nit
Official Funeral Directors Reg.or License#