O'Brien, Mary4 �C
N EW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last
Sex
Mary Elizabeth O'Brien
Female
Date of Death
Age
If Veteran of U.S. Armed Forces,
10/23/2019
88 Years
War or Dates
Place of Death Hospital, Institution or
2
City, Town or Village Queensbury Town Street Address 349 Cleverdale Road, Queensbury Town, New York 12820
W
W
Mannerof Death Undetermined Pending
Natural Cause Accident Homicide Suicide g
V
Circumstances Investigation
U1
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
156
Burial
Date
Cemetery, Crematory or Facility Name
10/24/2019
Pine View Crematory
Entombment
ICremation
Address
Queensbury, New York
Donation
Date
Place Removed
0
Removal
and/or
and/or Held
0
N
Hold
Address
0
d
Date
Point of
0)
p
❑ Transportation
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
"j
Address
Q
W
I'
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/24/2019 Registrar of Vital Statistics CaroC:nexfdgard, Bar6er(EkItrani-11ysy-er!%
(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:
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W
Date of Disposition Q Z3 9 Place of Disposition 7 17 2 tr j , Cc J �T�i✓IG_�D
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(address)
W
Q(section)
(lot number) (grave number)
Name of Sexton or Perso , Ch ge of Premises
O
z
W
(p! ase print/
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Signature ,'`- Title
DOH-1555 (o7/18) ¢1 of 2
Public Health Law Sec. 4145(2b)
013026
Receipt
Human remains of I delivered on
20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License #