Sovetts, Mary NEW YORK STATE DEPARTMENT OF HEALTH ( t 1
Vital Records Section Burial - Transit Permit
-,'- Name First Middle Last Sex
Mary Elizabeth Sovetts Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/23/2018 96 Years War or Dates
F- Place of Death Hospital, Institution or
tZ City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Ck W Manner of Death 0 Natural Cause ❑Accident ID Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
ui Medical Certifier Name Title
0 John Quaresima MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 46
'. El Burial Date Cemetery or Crematory
08/27/2018 Pine View Crematory
El Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Z=Removal and/or Held
2 and/or Address
Hold
fa
Er,IDate Point of
Transportation Shipment
by Common Destination
Carrier
ID
Disinterment Date Cemetery Address
El Reintermerit 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
t Remains are Shipped, If Other than Above
2 Address
W
iW
a" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/24/2018 Registrar of Vital Statistics Aimee Mahoney(E(ectronicafiySigned)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition iii 19 lir Place of Disposition f r .‘
W (address)
CO
re (section) (lot nu ber) (grave number)
QName of Sexton or Person in Charge Premises i r,. t, 51.4 Aft
Z (please print
W Signature JM� Title —mR f04 (over)
DOH-1555(02/20 4)