Kemmer, Grace Ann • A rriL
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Grace Ann Kemmer Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/04/2020 101 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
'p Mannerof Death 0 Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 552
Burial Date Cemetery,Crematory or Facility Name
12/07/2020 Pine View Crematory
Entombment Address
lCremation Queensbury,New York
Donation
0 1-1
Removal Date Place Removed
and/or and/or Held
F Hold Address
0
d Date - Point of
❑
U) Transportation
CI by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
ElReinterment 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
5 Address
Q
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/07/2020 Registrar of Vital Statistics P6erMnireuiCartir(E!ectronicall:y 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:
Z Date of Disposition ]2 l7 170 Place of DispositionUJ
,
2 (address)
W
CC N (section) A (lot number) (grave number)
it
0 Name of Sexton or Person in Charge of Pr miles es(6P print)
/ sl �
Z
W Signature L� ^ J Title
DOH-1555(o7/18)p i of 2
Public Health Law Sec. 4145(2b) 01 2 0
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#