Stewart, Jane M. r a _ tf, 770
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jane M.Stewart Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/18/2021 93 Years War or Dates
H Place of Death Hospital,Institution or
• City,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing
,Q▪ Manner of Death ❑X Natural Cause Ei Accident ❑Homicide Ej Suicide El Undetermined ElPending
U Circumstances Investigation
W Medical Certifier Name Title
G Jennifer Donovan DO
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 73
ElBurial Date Cemetery,Crematory or Facility Name
03/22/2021 Pine View Crematory
Entombment Address
ElCremation Queensbury Town,New York
ElDonation
Removal Date Place Removed
and/or and/or Held
Hold Address
CO
0
Date Point of
N ❑Transportation
a by Common Shipment
Carrier Destination
11 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
k- Remains are Shipped,If Other than Above
2. Address
Mi
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/22/2021 Registrar of Vital Statistics CarnfneNifrfegarrl Barber(EI ctronical 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:
Z Date of Disposition 3/Z3 /Z i Place of Disposition th ru 4.A
2 address)
IW
CC (section) number) (grave number)
QI._
O Name of Sexton or Person in Charge of Premises � 1 t�{ '''"^�' r
Z (please pr t)
W Signature Title r!t2v.;nr��yl
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 6 58
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#