Picone, Maureen a 31 Z_
NEW YORK STATE DEPARTMENT OF HEALTH i '
Vital Records Section Burial - Transit Permit
r�r%R Name First Middle Last Sex
Maureen E. Picone Female
Date of Death Age If Veteran of U.S. Armed Forces,
:, , May 13, 2014 61 War or Dates
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Place of Death Hospital, Institution or
City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
Manner of Death ! Natural Cause n Accident ❑Homicide Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Carlos Ares,MD
''fg Address
:,,
Glens Falls,NY 12801
,::, Death Certificate Filed
41 District Number Register Number
',A City, Town or Village Glens Falls,NY 5601 9
❑Burial Date Cemetery or Crematory
May 15, 2014 Pine View Crematorium
❑Entombment Address
I1 Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
W ❑Transportation Shipment
a by Common Destination
_ Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
i; Registration Number
/> Permit Issued to
if;
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
A 407 Bay Road, Queensbury, NY 12804
%
, Name of Funeral Firm Making Disposition or to Whom
, Remains are Shipped, If Other than Above
Address
c Permission is hereby granted to dispose of the human remains described above as,indicated.
Date Issued S / t 5 I (Li Registrar of Vital Statistics LAC 11. �.
i,,r. (signatu
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District Number 5601 Place Glens Falls,NY
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 5-1 6-144 Place of Disposition 4,,,, '
2 (address)
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W
0 (section)
1(lot number) C (grave number)
p Name of Sexton or Person i Charge of Premises Lt `�'e
Z (plea!e print)
W t Title C�
Signature
(over)
DOH-1555(02/2004)