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Mann, Kistina If • IZ(� NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kristina A Mann Female Date of Death Age If Veteran of U.S.Armed Forces, 11/14/2020 35 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address 9 Ogden Street,Glens Falls,New York 12801 'p Manner of Death © Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending V Circumstances Investigation W Medical Certifier Name Title Susan Muller MD Address 510 Geyser Road,Ballston Spa Village,New York 12020 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 517 ❑Burial Date Cemetery,Crematory or Facility Name 11/17/2020 Pine View Crematory ElEntombment Address Cremation Queensbury Town,Warren,New York ▪Donation Removal Date Place Removed and/or and/or Held N Hold Address O d Date Point of (I) ❑Transportation S by Common Shipment Carrier Destination 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 Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 2, Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/17/2020 Registrar of Vital Statistics Wp6ert Andrew Curtis(ECectronica1TySigned) (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: W Date of Disposition //-/9-ZO Zl3 Place of Disposition ?)10_,,v l' /'eyyraij41 (address) W CC CC (section) 1 (lot number) (grave number) J � Name of Sexton or Per n i Charge of Premises " //4✓1 (9G' (pleas me int/ Z W Signature Title c.10�� DOH-1555(07/18) 1of 2 / _ f Public Health Law Sec. 4145(2b) 014 210 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#