Nam, Sungae ,11 gfl
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ril
Name First Middle Last Sex
Sungae Nam Female
yµ Date of Death Age If Veteran of U.S. Armed Forces,
? 10/29/2018 82 Years War or Dates
's Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
` Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
Circumstances Investigation
Medical Certifier Name Title
Scott Biasetti MD
�"' Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
'. City, Town or Village Glens Falls 5601 508
t�,❑Burial Date Cemetery or Crematory
10/31/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
El❑Removal and/or Held
and/or
Address
`a Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment
Date Cemetery Address
t Date Cemetery Address
❑Reinterment
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
-; Permission is hereby granted to dispose of the human remains described above as indicated.
' Date Issued 10/31/2018 Registrar of Vital Statistics Qjg6ertA Curtis(ECectronicaltySigned)
(signature)
F 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:
Date of Disposition A i Z jig Place of Disposition ?v4w ��...ii1'
(address)
Ili
(section) `�(lot number (grave number)
p Name of Sexton or Person in Charge of Premises ` h twol
z (pi Skase print)
W Signature !✓' Title ltinit Mg
(over)
DOH-1555(02/2004)