Biddiscombe, MaryAnn NEW YORK STATE DEPARTMENT OF HEALTH 141
Vital Records Section Burial - Transit Permit
": Name First Middle Last Sex
Mary Ann Biddiscombe Female
%�%,:
Date of Death Age If Veteran of U.S. Armed Forces,
, ;: May 11,2016 72 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Undetermined Pending
. Manner of Death g Natural Cause n Accident Homicide 0 Suicide � n
Circumstances Investigation
Medical Certifier Name Title
Shahid Ahmed,Doctor
i,! Address
% Glens Falls,NY
rf;
A Death City, Town o' lcat r Vil g Glens Falls, NY 5601 Filed District NumberRegister Number /3'
❑Burial Date Cemetery or Crematory OO''�-11
May 16, 2016 Pine View Crematorium
❑Entombment A_-+,,: s
Ei Cremation t'1 er Road ueensbur , NY 12804
t..,.-to
, Place Removed
Z ❑Removal 4u=, and/or Held
O and/or iddi•ess,` ,
H Hold
U) - r
0 I Date `'' Point of
W ❑Transportation Shipment
'p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
y Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
r;,
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1` Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
;r;`a Date Issued 5 1 3) 2 )6 Registrar of Vital Statistics , Q..l..i`'YYQ 1A) Ct-
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(signature
:
; e C91V-���.><�- District Number 5(��?t Place � \��
I certify that the remains of the decedent identified above were disposed of in accordahce with this permit on:
Lu Date of Disposition c-lei-IL Place of Disposition IL avravtdfcv
(address)
W
CO
W (section) /! (lot numb ) (grave number)
pName of Sexton or Person in Charge o Premises `G.ns
Z ( lease print)
WA p��.
Signature Title geivvl
(over)
DOH-1555(02/2004)