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Werner, Lucille Ann II 50g NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Lucille Ann Werner Female Date of Death Age If Veteran of U.S.Armed Forces, 06/18/2021 78 Years War or Dates ZPlace of Death Hospital,Institution or City,Town or Village Moreau Town Street Address 327 Lamplighter Acres,Moreau Town, New York 12828 ,p Manner of Death ©Natural Cause ❑Accident El Homicide 111 Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title Aimee Mcmaster Nurse Practitioner,Acute Care Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 ▪Burial Date Cemetery,Crematory or Facility Name 06/21/2021 Pine View Crematory Entombment Address ▪Cremation Queensbury,New York ▪Donation Z Removal Date Place Removed and/or and/or Held Hold Address N 0 a Date Point of tl1 1-1 Transportation p by Common Shipment Carrier Destination El 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 Remains are Shipped,If Other than Above Address C w IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/21/2021 Registrar of Vital Statistics Leeann 99Kc ca6e(E(ectronica((y Signed) (signature) District Number 4562 Place Moreau, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition /Mt l,+ Place of DispositionUJ Dh--- 2 (address) W (section) /) (lot number) (grave number) SName of Sexton or Person in Charge of Prem' es f+I"ttL t'' �1 Z /pte se print) W Signature Z Title L�^"t DOH-1555(07/18)p l of 2 #OS110011 JO•fag szolaaIQ IEJaund 1 UJO liuuad ieunq uo paunvu auzgq In.ztznj alp Suraizasazdag S.zalauzaD morA auk; , OZ uo pa.zanHap Jo sureuiaz ueuznH ldioo >j 9L 81 T O (gZ)Sj7il 'aas u I H arignd