Backes, Mary Ann tt
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mary Ann Backes Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/12/2021 69 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address 3 Mabel Terrace,Queensbury Town, New York 12804
`p Manner of Death ❑X Natural Cause ❑Accident Homicide ❑Suicide Undetermined El Pending
Circumstances Investigation
WMedical Certifier Name Title
0 Noelle Stevens MD
Address
100 Broad Street,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 208
▪Burial Date Cemetery,Crematory or Facility Name
10/15/2021 Pine View Crematory
0 Entombment Address
Cremation Queensbury Town,New York
❑Donation
O Removal Date Place Removed
and/or and/or Held
NH Hold Address
0
Q. Date Point of
U) Li Transportation
p 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
F. Remains are Shipped,If Other than Above
a Address
W
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/13/2021 Registrar of Vital Statistics Carolinexkligarf Barber(Electronicaf Segued)
(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:
F
WDate of Disposition /`D..t6_-fez,/ Place of Disposition /',n do 1,e ,) �j�:�✓t
2 (address)
W
CO
(section) (lot number) (grave number)
8 Name of Sexton or Person i arge of Premises )r 44-1 6444- 4
Z (please print)
LIJ
Signature Title �_i�✓✓ems y
DOH-1555(07/18)p 10 2
,,: 2
r.) r�
Public Health Law Sec. 4145(2b)
1 Receipt
1
IHuman remains of delivered on , 20 '
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Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#