Logue, Jeanne It 14/Z
NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jeanne Logue Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 19,2013 92 War or Dates
F,. Place of Death Hospital, Institution or
Z City, Town or Village Kingsbury Street Address 177 Hartman Road
pManner of Death ]Natural Cause Accident ❑Homicide Suicide Undetermined Pending
W Circumstances Investigation
w Medical Certifier Name Title
Raymond Kruk NP
Address
66 Middledugh Rd,Wappinger Falls,NY 12590
Death Certificate Filed District Number Register Number
City, Town or Village Kingsbury /3
❑Burial Date Cemetery or Crematory
August 23,2013 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ El Removal and/or Held
and/or Address
E Hold
in
0 Date Point of
N Transportation Shipment
'p by Common Destination
Carrier
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
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued g a/-aOf3 Registrar of Vital Statistics o1 /IIR
(signature)
S7L
District Number JCingchnry Place Kingsbury , J j� , ,,- yr
�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition $/13113 Place of Disposition 'w` f
2 (address)
W
(section) _ ( t number) r (grave number)
Name of Sexton or Person in Charge of Premises f r, 3Aidif
Z
lease print)
W Signature Title C'12EIo9Tdt2
(over)
DOH-1555(02/2004)