Lansley, Mack William # 6
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Male
Mack William Lansley
Date of Death Age If Veteran of U.S.Armed Forces,
05/03/2021 2 Days War or Dates
r Place of Death Hospital,Institution or
W
City,Town or Village Albany Street Address Albany Medical Center Hospital
W Manner of Death ❑X Natural Cause ❑Accident El HomicideSuicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
C Marilyn Fisher MD
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed District Number Register Number
City,Town or Village Albany 0101 1162
Burial Date Cemetery,Crematory or Facility Name
05/06/2021 Pine View Crematory
0 Entombment Address
gCremation Queensbury,New York
0 Donation
Z ❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
Date Point of
co ❑Transportation Shipment
G by Common
Carrier Destination
Date Cemetery Address
ElDisinterment
Date Cemetery Address
0 Reinterment
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
_• Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/06/2021 Registrar of Vital Statistics Daniell Sczlle pse(Electronica*Signer!)
(signature)
District Number 0101 Place Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i—
WDate of Disposition 5-11 I"ti Place of Disposition il"2 �n. L Or—'
(address)
IL
CC (section) t number) (grave number)
0 r., L. SNn.t(t'
o Name of Sexton or Person in Charge of Premise 6pleas�print)
Z r ��ilt
W Signature Title
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b) = x
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#