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Perrelli, Ursula riti /0 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle / Last Sex Ursula Perrelli Female Date of Death Age If Veteran of U.S.Armed Forces, ' 12/15/2021 81 Years War or Dates Place of Death Hospital,Institution or ILi City,Town or Village Queensbury Town Street Address 222 Upper Sherman Avenue,Queensbury Town,New York 12804 p Manner of Death ©Natural Cause ❑Accident 0 Homicide 0 Suicide 11 Undetermined 1=1 Pending IIV Circumstances Investigation Ii' Medical Certifier Name Title © Mary Stein NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District N er Register Number City,Town or Village Queensbury 5657 240 ❑Burial Date Cemete�Crematory or Facility Name 12/17/2021 Pine Vie Crematory ❑Entombment Address 0 Cremation Queensbury Town,New York ElDonation Z ❑Removal Date Place Removed cand/or and/or Held 1- Hold Address 0 CL Date Point of N❑Transportation Shipment p, by Common Carrier Destination Date Cemetery Address .❑Disinterment . 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 ILI . Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/16/2021 Registrar of Vital Statistics Caroline JfiCdegarife Barber(ECectronicalty Signed) (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: Z Date of Disposition II.in III Place of Disposition Zsii� C or,u...1. W (address) ILIJ (section) 4 (lot number) e (grave number) Name of Sexton or Person in Charge of Premises (`iV-...... Sih'14,itW 7 /plprint/ �,�,„ Signature Title "�'� �1D�' DOH-1555(07/18)p 1 of 2 01.54F2 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#