Lacombe, Mary s �
nIR
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Agnes Lacombe Female
Date of Death Age If Veteran of U.S. Armed Forces,
02/28/2018 100 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death X❑Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Jennifer White DO
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 134
❑Burial Date Cemetery or Crematory
03/05/2018 Pine View Crematory
['Entombment Address
®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
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 Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/01/2018 Registrar of Vital Statistics John PPranck(EfectronicaffySigned)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3/ s I11 Place of Disposition ,.. 4;4
(address)
(section) 4(154 numb (grave number)
Name of Sexton or Person in Charge of Premises ��"
(pl se print)
Signature Li Title (I t1 RA.
(over)
DOH-1555 (02/2004)