Logan, Mary I
'int0C/
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
e. Name First Middle Last Sex
ri Mary Kay Logan Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 25,2014 73 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death j Natural Cause El Accident El Homicide 0 Suicide EUndetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Robert W.Sponzo
Address
Cancer Center,102 Park St,Glens Falls,NY 12801
r Death Certificate Filed District Number Registei;. urtAber
City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
September 29,2014 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ ri Removal and/or Held
and/or Address
H Hold
t/N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
E
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
t Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
xv Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9/2 //i-/ Registrar of Vital Statistics GO CLA41.-QAW
r (signature)
0
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:
I-
ui Date of Disposition qi/oilof Place of Disposition 19ottata 6-i.O'4..-
(address)
W
N
sz (section) /}' (lot number) (grave number)
pName of Sexton or Person in Charge of Premises At,) J?M.�lf
Z lease print)
W Signature e.- 4. Title tivE 1t1 Mot
(over)
DOH-1555(02/2004)