Mayo, Audrey L. # ily
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Audrey L.Mayo Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/18/2021 83 Years War or Dates
1— Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 39 Longview Drive 133,Queensbury Town,New York 12804
W Manner of Death ❑X Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Charles Yun MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number 1 Register Number
City,Town or Village Queensbury 5657 52
ElBurial Date Cemetery,Crematory or Facility Name
02/19/2021 Pine View Crematory
❑Entombment ,Address
g Cremation Queensbury Town,New York
❑Donation
O ❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
O. Date Point of
U) ❑Transportation
Q by Common Shipment
Carrier Destination
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
t Remains are Shipped,If Other than Above
a Address
LC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/18/2021 Registrar of Vital Statistics Caroliinexaigari Bader(E/ctronica(Signed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZW Date of Disposition 2 i 11 I 1,1 Place of Disposition .�L. 4-4-1 Or.--
2 (address)
W
CC (section) (lot numvhx-r (grave number)
D Name of Sexton or Person in Charge of Premis /, h(A
Z L..
(please print/
W Signature /1:9 Title ay011iQ
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 1
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#