McNally, Kathleen b //
- lei9 7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Iiilil Name First Middle Last Sex
Kathleen Joann McNally Female
Mi Date of Death Age If Veteran of U.S. Armed Forces,
>''' September 3, 2017 38 War or Dates n/a
1.' Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death n Natural Cause E Accident i l Homicide n Suicide Undetermined n Pending
13 Circumstances Investigation_
Medical Certifier Name Title _
(--Clress
Death Certificate Filed District Number Register Number
iNi City, Town or Village Glens Falls, NY 5601 !Li _
❑Burial Date Cemetery or Crematory
El Entombment September 6, 2017 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
E Hold
N
0 Date Point of
135 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
Permit Issued to Registration Number
>; Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
><] Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
:. s
.., ,
N. Permission is hereby granted to dispose of the human remains described above as indicated.
r' Date Issued I G 1 6 (2017 Registrar of Vital Statistics RWA-k_W-Igr-e�,� c
(signature)
District Number s( 0 ( Place 6 CQM S t ' us
bur y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Vy/7
in Date of Disposition Place of Disposition /�/Fi 2 V I' C' fey �
fv(address)
W
N
le (section) J jlot number) (grave number)
pName of Sexton r ' Charge of Premises IA-t r c.--✓1 (0Ct rn4-4-4,
Z (please print)
LL1
Signature Title e.._,wrt-a..
(over)
DOH-1555(02/2004)