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Burt, Theresa Marie 2Lj NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Theresa Marie Burt Female Date of Death Age If Veteran of U.S.Armed Forces, 03/02/2021 51 Years War or Dates f,. Place of Death Hospital,Institution or WCity,Town or Village Bolton Town Street Address 36 Rainbow Drive,Bolton Town,New York 12824 pManner of Death ©Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined ❑Pending V Circumstances Investigation W Medical Certifier Name Title CI Christopher Mason DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Bolton Landing 5650 3 Burial Date Cemetery,Crematory or Facility Name 03/04/2021 Pine View Crematory ❑Entombment Address ElCremation Queensbury,New York ❑Donation go Removal Date Place Removed and/or and/or Held Hold Address 0 a Date Point of co ❑Transportation Shipment p by Common Carrier Destination Date Cemetery Address ❑Disinterment 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 H Remains are Shipped,If Other than Above 2 Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/04/2021 Registrar of Vital Statistics Jodi Petteys(E(ectronicaCCy Signed) (signature) District Number 5650 Place Bolton Landing, 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 Place of Disposition � e ,.c ,^erpt (address) 1J NCC (section) (lot number) (grave number) SName of Sexton or Person in Ch e of Pre is )' 7 yfi7 1 r Z (please print) W Signature 'F�7 1 ie1 i L`, Title © -t'J''rje) DOH-1555(07/18)p i of 2 Public Health Law Sec. 4145(2b) 014610 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#