Persutti, Alice J 4 871
NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Alice J Persutti Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/21/2021 88 Years War or Dates
N Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide
V Circumstances Investigation
W Medical Certifier Name Title
C Michael Miles MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 457
Burial Date Cemetery,Crematory or Facility Name
10/22/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
Hold Address
CO
0
a Date Point of
t/! Li Transportation Shipment
G by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
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
1- Remains are Shipped,If Other than Above
2 Address
fZ
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/22/2021 Registrar of Vital Statistics I',odert,7ndrew Oath(Electronicallj,Srgnerl)
(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:
Z u � d
W Date of Disposition ln123IZ1 Place of Disposition �nt is.,..
2 (a dress)
W
CC (section) A (lot number) (grave number)
gName of Sexton or Person in Charge of Premises (A-0, e. 1,t
Z Weise se print)
W (%/// TitleC 'N
Signature
DOH-1555(o7/t8)p t of 2
015246
Public Health Law Sec. 4145(2b)
Receipt
Human remains of 11, delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License# ` �. 1