McDonald, Marie 41 ill
NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marie A. McDonald Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 24, 2013 62 War or Dates
i.,. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
ip Manner of Death a Natural Cause 0 Accident n Homicide Ei Suicide ri Undetermined El Pending
Circumstances Investigation
GMedical Certifier Name Title
Amy Hogan-Moulton MD
Address
2 Broad Street,Glens Falls,NY 12801
Death Certificate Filed Glens Falls District Number Regis/Number
City, Town or Village 5601
❑Burial Date Cemetery or Crematory
Entombment November 26,2013 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZO E Removal and/or Held
and/or Address
H Hold
O Date Point of
N Transportation Shipment
p 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 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2 Address
W
a Permission is h reby granted to dispose of the human mains escribed bove as i =d.
Date Issued/ ? Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls /A QV/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition It- l313 Place of Disposition � t r.,et7irt•.,
W address)
N
GO g (section) (lot number)( (grave number)
Name of Sexton or Person in Charge f Premises ra
Z lease print)
W
Signature Title Clo 1 FOI ,
(over)
DOH-1555(02/2004)