Mitchell, Janet NEW YORK STATE DEPARTMENT OF HEAL`fH a
Vital Records Section Burial - Transit Permit
'' Name First Middle Last Sex
'< Janet Mitchell Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 29, 2013 68 War or Dates
j Place of Death Hospital, Institution or
Z. City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death n Natural Cause I I Accident E Homicide [1 Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Jennifer Stratton MD
Address
14 Manor Drive,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 5711
❑Burial Date Cemetery or Crematory
❑Entombment January 2, 2014 Pine View Crematory
Address
CI Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ' Removal and/or Held
and/or Address
H Hold
to
O Date Point of
yn Transportation Shipment
p by Common Destination
Carrier
U 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
I— Remains are Shipped, If Other than Above
Address
W
Q. Permission is hereby gran ed to dispose of the human remains cribed above as in, icate,,.
r
Date Issued Q Registrar of Vital Statistics i /�� L G
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
Z
Date of Disposition I /3)►y Place of Disposition Zv e,,,t.C(7J,t�„
W (address)
co
0 O (section) (lot number) (grave number)
p Name of Sexton or Perso in Charge o Premises r,stotor -v,,,tr Z
W (please print)
Signature Title at Td„L
(over)
DOH-1555(02/2004)