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Mather, Dorothy Ellen NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dorothy Ellen Mather Female Date of Death Age If Veteran of U.S.Armed Forces, 01/30/2022 93 Years War or Dates Place of Death Hospital,Institution or la aZ City,Town or Village Queensbury Town Street Address 30 Hall Road,Queensbury Town,New York 12804 Manner of Death ©Natural Cause 0 Accident ❑Homicide ❑Suicide Undetermined ❑Pending W Circumstances Investigation liE Medical Certifier Name Title Mary Stein NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number - City,Town or Village Queensbury 5657 27 ❑Burial Date Cemetery,Crematory or Facility Name 02/03/2022 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury,New York ❑Donation Z Removal Date Place Removed and/or and/or Held N Hold Address O CL 1-1 Date Point of to Li Transportation p by Common Shipment Carrier Destination 1-1 Li 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 a Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/03/2022 Registrar of Vital Statistics Caroline 2fiCdegarde 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: i% Date of Disposition 2--3-7--- 2-yPlaceof Disposition 2 (address) W N CC (sedan) (lot number) (grave number) cp S Name of Sexton or Per 2hae of Premises e.,TM e, SRvitc ease print) W Signature Title c,Ce,rvg1LGC- DOH-1555(07/18)p i of 2 015604 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#