LoCascio, Jane L NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jane L.LoCascio Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/07/2021 77 Years War or Dates
I._ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause 0 Accident Ei Homicide ❑Suicide 12 Undetermined El Pending
W 0 Circumstances Investigation
Ili Medical Certifier Name Title
Marvin Davidowitz MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 90
Burial Date Cemetery,Crematory or Facility Name
02/13/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury,New York
0 Donation
• Removal Date Place Removed
and/or and/or Held
F Hold Address
0
a Date Point of
N) ❑Transportation Shipment
fl by Common
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
j;. Remains are Shipped,If Other than Above
2 Address
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/10/2021 Registrar of Vital Statistics Ro6ert_fitulrewCurtir(Ekctronica(S{gnei9
(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:
I-
Z Date of Disposition 9_j;j-204/ Place of Disposition -p 1J e U;e e t-,
(addr )
W
N CC (section) (tot number) (grave number)
�
g Name of Sexton or Person in Cha e of Premises ')4 V":0,41 7 E- U)ta
ri
(please print)
W Signature I i 1,v Title ��Qh2 r-
DOH-1555(07/18)p 1 of 2
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#