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Bjoin, Yolanda K NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit� t Bureau of Vital Records Name First Middle Last Sex Yolanda K Bjoin Female Date of Death Age If Veteran of U.S.Armed Forces, 11/21/2020 64 Years War or Dates Place of Death Hospital,Institution or Z W City,Town or Village Wilton Town Street Address 901 Heritage Way,Wilton Town, New York 12831 Ili Manner of Death ❑Natural Cause ❑Accident El Homicide ❑Suicide El Undetermined ©Pending Circumstances Investigation W Medical Certifier Name Title CI Danielle Jourdan Coroner Address 4205 Route 50,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Gansevoort 4569 52 ❑Burial Date Cemetery,Crematory or Facility Name 11/24/2020 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation 6- El Removal Date Place Removed and/or and/or Held H Hold Address in 0 a. Date Point of ❑to Transportation E.) by Common Shipment Carrier Destination El Disinterment Date Cemetery Address El 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 E.. Remains are Shipped,If Other than Above g Address O W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/24/2020 Registrar of Vital Statistics Susan Baldwin(Electronically Signed) (signature) District Number 4569 Place Gansevoort, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition I11T/170 Place of Disposition .?,iL W (addre s/ W CC (section) //b�/lot number) (grave number) S G 11 r.4 1., ��►4iIF Name of Sexton or Person in Charge of Pre s (p/ea print) W 1. Signature Title �,2 DOH-1555(07/18)p 1 of 2 4231 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#