Hayden, Ann NEW YORK STATE DEPARTMENT OF HEALTH.s 1 # Vi
Vital Records Section Burial - Transit Permit
Name First - Middle Last Sex
Ann K. Hayden Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 25, 2014 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death®Natural Cause Accident ❑Homicide El Suicide Undetermined ri❑Pending
.i Circumstances Investigation
tit Medical Certifier Name Title
p Jennifer Stratton, MD
.Address
161 Carey Road, Queensbury, NY 12804
Death Certificate Filed District Number Register Number
i City, Town or Village Glens Falls, NY 5601
M'i0Burial Date Cemetery or Crematory
Entombment December 29, 2014 Pine View Crematorium
Address
gig 0Cremation quaker Road, Oueensbury, NY 12804
Date Place Removed
K1-1Removal and/or Held
g and/or Address
M= Hold
- Date Point of
t El Transportation Shipment
ES by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 •
Address 407 lay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I
tU
Permission is hereby granted to dispose of the human remains des ribed abo e as' . ated.
ggi Date Issued Registrar of Vital Statistics ,,/�/.
(signature)
lilli 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:
ILI ,�, �
Date of Disposition It(3c�(f4 Place of Disposition �� `"ef+xti..-
(address)
Ui
CC (section) (lot number (grave number)
0
CI Name of Sexton or Person in C arge of Premises A ' '*f
Z r (please print)
la Signature !/` Title �It+!A '�
(over)
DOH-1555 (02/2004)