Donovan, Anne NEW YORK STATE DEPARTMENT OF HEALTH
E #
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anne Donovan Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 25, 2014 94 War or Dates No
}„ Place of Death Hospital, Institution or
Z City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
tLI
Manner of Death Natural Cause n Accident n Homicide Suicide n Undetermined Pending
L Circumstances Investigation
g; Medical Certifier Name Title
3 Eileen Spinelli Anp-Bc
Address
Queensbury,NY
Death Certificate Filed District Numbe5755 RegiAr Number
City, Town or Village Town Of Fort Edward (if
El Burial Date Cemetery or Crematory
4149/i`t Pine View Crematorium
El Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
Hold
Cl)
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n 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
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
Permission is h reby granted to dispose of the human a ins describe abo? as i icated.
Date Issued Registrar of Vital Statistics � '1/ '.
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Ili(IC Place of Disposition „u,,, e ,.
2 (address)
W
r (section) G'� (lotnum � (grave number)
Op Name of Sexton or Person in Charge of remises r pL, r
Zr (please print)
Signature
W Title CIZ iM111U4
(over)
DOH-1555(02/2004)