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Havern, Patricia NEW YORK STATE DEPARTMENT OF HEALTH 1► (31 Vital Records Section i Burial - Transit Permit Name First Middle Last Sex Patricia A. Havern Female <; Date of Death Age If Veteran of U.S. Armed Forces, December 2, 2012 77 , War or Dates Place of Death Hospital, Institution or ' City, Town or Village Glens Falls Street Address Glens Falls Hospital vs Manner of Death X Natural Cause ( I Accident Homicide n Suicide ' Undetermined Pending tISCircumstances Investigation Medical Certifier Name Title Amy Hogan-Moulton Address Glens Falls,NY 4:, Death Certificate Filed District Number Register Number City, Town or Village Glens Falls,NY 5601 rj Li q 0 Burial Date Cemetery or Crematory ❑Entombment December 4,2012 Pine View Crematorium Address ©Cremation 21 Quaker Road, Queensbury,NY 12804 Date Place Removed Z n Removal and/or Held O and/or Address F' Hold N 0 Date Point of l I 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 iii 407 Bay Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom i::: Remains are Shipped, If Other than Above S Address CZ US >Ck: Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued i z/ 3/t, Registrar of Vital Statistics V"C,Livi-r,p W (signature District Number 5601 Place Glens Falls,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Oi,tj Date of Disposition 1 Z 142 Place of Disposition „� Lu (address) Cl) IX (section) (lot numbel�, (grave number) p Name of Sexton or Person in Charge o Premises Ati}igpL J1 Z I(please print) LL! Signature IL g Title CI-074 (over) DOH-1555(02/2004)