LaPann, Mary Ellen �# 4 371
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
7 Name First Middle Last Sex
• Mary Ellen LaPann Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/06/2018 60 Years War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑Accident ❑Homicide El Suicide El Undetermined El❑Pending
LU Circumstances Investigation
La Medical Certifier Name Title
CI Jennifer Stratton MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 226
❑Burial Date Cemetery or Crematory
05/10/2018 Pine View Crematory
'1 El Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
in❑Removal and/or Held
and/or Address
Hold
Date Point of
1❑Transportation . Shipment
$ by Common Destination
• Carrier
ID Disinterment
Date Cemetery Address
-- Date Cemetery Address
s❑Reinterment
i
4 Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
• Address
407 Bay Rd,Queensbury,New York 12804
t Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
SiAddress
FPermission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/09/2018 Registrar of Vital Statistics c96ert A Curtis(ECectronicalty Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui Date of Disposition ;hi II Place of Disposition 64.,, 1:4—.1..,
2 (address)
U
Its (section) /k (lot number) ("` (grave number)
aM.Name of Sexton or Person in Charge of Pre ises .. L )'..�4+
z (pease print)
W9
Si nature '^'� ri Title MO P1
(over)
DOH-1555 (02/2004)