Fuller, Patricia K. N EW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Patricia K Fuller 7Female
--[Date of Death Age If Veteran of U.S.Armed Forces,
03/11/2020 67 Years War or Dates
H. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
p Mannerof Death ®Natural Cause Accident Homicide 1:1Suicide Undetermined Pending
LL1 Circumstances Investigation
U
W Medical Certifier Name Title
Q Kelly Maley PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 118
Burial Date Cemetery,Crematory or Facility Name
03/12/2020 PineView Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
z Removal Date Place Removed
and/or and/or Held
E- Hold Address
N
0
(L Date Point of
V) ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 101117
Address
18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/11/2020 Registrar of Vital Statistics Robert Andrew Curtis(Electronically 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:
H
Z Date of Disposition J Place of Disposition fyn,y ef�r
W
2 (address)
W
(n
a: (section) (lot number) (grave number)
O „f�5
o Name of Sexton or Person in Charge of Premises �y
Z % (please print)
W Signature Title
'04
DOH-1555(07/18)p 1 of 2
F
Public Health Law Sec. 4145(2b) t 'y
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named Qn.bu€ial.permit
Official Funeral Directors Reg.or License# % ''