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Shires, A Jane 4bZ( NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex A Jane Shires Female Date of Death Age If Veteran of US.Armed Forces, 07/28/2021 102 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Johnsburg Town Street Address Elderwood at North Creek 'p Manner of Death © Natural Cause ElAccident ElHomicide ElSuicide ❑Undetermined ❑Pending U Circumstances Investigation ILI G Medical Certifier Name Title James Hindson MD Address 112 Ski Bowl Rd,Johnsburg Town,New York 12853 Death Certificate Filed District Number Register Number City,Town or Village North Creek 5655 26 ❑Burial Date Cemetery,Crematory or Facility Name 08/02/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury,New York ❑Donation Z ❑Removal Date Place Removed and/or and/or Held - Hold Address 0 O. 1-1 Date Point of CO Li Transportation 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 Remains are Shipped,If Other than Above 2 Address I Ili a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/30/2021 Registrar of Vital Statistics ?(atkreen C.Lorah(EfectronicaffySigned) (signature) District Number 5655 Place North Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 3 Date of Disposition $� �2 Place of Disposition it�r,,aL �✓I � (address) W CC (section) �/� (lot numbe (grave number) ict 8 Name of Sexton or Person in Charge of Premis t ��" 1n^" Z (lease print/ �11 ,,-� W Signature — Title � M't�'K DOH-1555(07/18)p i of 2 `4 ` Public Health Law Sec. 4145(2b) 0 1 n c 9 4 Receipt Human remains of delivered on _ , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#