Irvine, Anna • a
14
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anna M. Irvine Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 1, 2017 89 War or Dates NA
Place of Death Hospital, Institution or
City, Town or Village Town of Queensbury Street Address 37 Marcy Lane, Queensbury, NY
Manner of Death I)(I Natural Cause n Accident n Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
William Borgos MD
Address
Carey Rd.Queensbury,NY
02 Deat cate FiledC District Number Register Number
- City, Towcr Village 1,t,e..e_� jt e�r S(9S� I
❑Burial Date Cemetery or Crematory
February 3, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
H Hold
W
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
['Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
/ Address
N 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
p
Permission is hereby granted to dispose of the human rem n desc ' boy a n ' ated.
A Date Issued D,,-�-a-O►•--, Registrar of Vital Statistics o.LuQ A.
(signature
4
or District Number ` (61 Place 6tN�.
F I certify that the remains of the decedent identified above 4
disposed of in accord ce ith this permit on:
�• Date of Disposition *in Place of Disposition tg, ,,.a,
W (address)
Cl)
re (section) I,/ (lot number) [ (grave number)
Q Name of Sexton or Person in Charge of Premises ` hruhv J pi4►Il'f
Z (pl ase print)
tu
Signature [.i / Title "r tP&
(over)
DOH-1555(02/2004)