Singleton, Elizabeth Ann NEW YORKSTATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Elizabeth Ann Singleton Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/11/2020 75 Years War or Dates
.., Place of Death Hospital,Institution or
City,Town or Village Charlton Town Street Address 59 Crooked Street,Charlton Town,New York 12148
Uj Manner of Death Natural Cause Accident Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
t Medical Certifier Name Title
[� Mina Sun MD
Address
115 Saratoga Road,Glenville Town,New York 12302
Death Certificate Filed District Number Register Number
City,Town or Village Charlton 1 4551 20-12
❑Burial Date Cemetery,Crematory or Facility Name
05/15/2020 Pine View Crematory
Entombment Address
X❑Cremation Queensbury,New York
Donation
❑Removal Date Place Removed
H and/or and/or Held
N Hold Address
EjTransportation 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
Remains are Shipped,If Other than Above
Address
Ul
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/14/2020 Registrar of Vital Statistics BreffdaLM,&(--kctronrcatySyffed)
(signature)
District Number 4551 Place Charlton, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t
W Date of Disposition /�=ZU2C�Placeof Disposition /?t>1e V! r-
',� (address)
W
N
(section) latnumber/ "" � (grave number/
Name of Sexton or Person' ha of Premises �>ti�!Q Lc I'1'! 6z.4,e
W (please print)
Signature Title G�'G���'
DO H-1555(07/18)p t of
Public Health Law Sec. 4145(2b) _
Receipt
Human remains of delivered on , 20
1
r '
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#