Bisignano, Lola 74-
4 i 773
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
be' Name First Middle Last Sex
•• Lola M. Bisignano Female.�
A. Date of Death Age If Veteran of U.S. Armed Forces,
r December 9, 2014 87 War or Dates
irr. Place of Death Hospital, Institution or
City, Town or Village Ft. Edward Street Address Fort Hudson Nursing Home
Manner of Death 1:
I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Carrie Miren RPAC
r Address
•
Y;9 Carey Road,Queensbury,NY 12804
;jrj Death Certificate Filed District Number Registe,ri umber
�; City, Town or Village Fort Edward 5755 (LI
❑Burial Date Cemetery or Crematory
December 12, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F' Hold
N
0 Date Point of
05 n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
' . Permit Issued to Registration Number
x.; e; 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
0 Permission is hereby granted to dispose of the huma r 'ns described a ove a indicated.
rr I�; Date Issued (2- aQ('l-( Registrar of Vital Statistics l.� i �r L✓----.
(signature)
r . District Number 5755 Place 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 It.I Iij Place of Disposition ,�, V_� ff� 04,_
2 (address)
W
Cl)
0 (section) number) (grave number)
Q Name of Sexton or Person in Charge f Premises dot
�i S u,.�
Z (ple a print)
Signature 4 Title LL
(over)
DOH-1555(02/2004)