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Kane, Elaine A
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Elaine A.Kane Female Date of Death Age If Veteran of U.S.Armed Forces, 11/06/2021 79 Years War or Dates F. Place of Death Hospital,Institution or W City,Town or Village Fort Edward Town Street Address 5 Griffin Avenue, Fort Edward Town, New York 12828 'p Manner of Death ©Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title Q 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 Fort Edward 5755 65 ❑Burial Date Cemetery,Crematory or Facility Name 11/09/2021 Pine View Crematory ❑Entombment Address lCremation Queensbury Town,New York ▪Donation z• Removal Date Place Removed and/or and/or Held N Hold Address 0 d Date Point of ❑(t) 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 tRemains are Shipped,If Other than Above • Address W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/08/2021 Registrar of Vital Statistics Aimee L Maloney(ECectronicalTy Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition /i0I,,] Place of Disposition tiILILI 2 (address) W CC (section) if(lot number) (grave number) SName of Sexton or Person in Charge Qf Premises Z (plead print) W Signature Title t arit DOH-1555(07/18)p 1 of 2 ` 0 .5" 16 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#