Falletta,Jane 43l
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jane Falletta Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/06/2022 88 Years War or Dates
F.. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide
Circumstances Investigation
W Medical Certifier Name Title
CI Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 89
▪Burial Date Cemetery,Crematory or Facility Name
02/09/2022 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
Donation
to
0 Removal Date Place Removed
and/or and/or Held
N Hold Address
0
0. 1-1 Date Point of
N ❑Transportation
p by Common Shipment
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
1— Remains are Shipped,If Other than Above
a Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/09/2022 Registrar of Vital Statistics MeganYoliin(EI ctronicaf Signed)
(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:
W Date of Disposition �—l Q—�� Place of Disposition D;r ?/,G l,,/ (/(t/h�{10 /
2 (address)
W
Q (section) (lot number) (grave number)
8 Name of Sexton or Pers in Charge of Premises e,rmtiy S 'red
(please print)
W Signature Title � 2mQio(
DOH-1555(o 18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
' `
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burialpermit
Official Funeral Directors Reg.or License#