Matteson, Viola ii..3NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Viola P Matteson Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/02/2022 94 Years War or Dates
I—, Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
W Manner of Death Undetermined Pending
Ei Natural Cause IllAccident Homicide Suicide g
tti
Circumstances Investigation
WMedical Certifier Name Title
a Came Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 21
X Burial Date Cemetery,Crematory or Facility Name
03/09/2022 Pine View Cemetery
Entombment— Address
Cremation Queensbury,New York
Donation
ZRemoval Date Place Removed
and/or and/or Held
(- Hold Address
N
0
O. Date Point of
N III Transportation
Q by Common Shipment
Carrier Destination
E
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
i}- Remains are Shipped,If Other than Above
S Address
51
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/04/2022 Registrar of Vital Statistics Aimee£Mahoney(ECectronicallySigned)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3.q D Z Place of Disposition 0‘ Q ua c Q,b (L� c n3 � S\ t ads
UJ
g a dress/ v ^}
N C4�;e. � -51 a
Q (section) (lot number) (grave number)
8 Name of Sexton or Person in Charge of Premises ,"I.C. .2.3c-
z (please print)
W Signature Title —Lpr t nNU\-ck t1*
/.4•0.4.;.1. •ey..
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b)
012902
Receipt
Human remains of delivered on , 20_
Pine View Cemetery Representing the funeral home named on burial permit
-
Official Funeral Directors Reg.or License#
MATTESON 4.F) Lot No. 36 A. 37
Address 12, SecondSection No.
St., Glens Falls, N.Y.
Owner My Ma}•tacnn Plot Oneida
Date : 10/17/78
200 Superficial ft. @ $2.50 per sq. ft.
Location Bounded on the North by P1th, East by Vacant, South by Webb, West by Road.
Corner Posts
Remarks
Deed No. (and changes) 1507
Payment Record raid in full 10/17/78
Form No. 01
Record of Interments
1 5
2 io�d cc.v -CSon 3 -9••- -D 6 Ik Kevin L . Matteson 10/17/98
S Myron B. Matteson 4/16/02 7 �
4 8
17,}C:/ r
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i
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Matteson
NAME Viola Matteson LLL•••••• Age: 94
Lot Owner: Myron & Viola Matteson
Lot# Oneida 36 & 37 Grave# 2
Case: Concrete
Died: 3 ,2.2 2 Interred: 3. 9.2 2
Funeral Home: Singleton Sullivan Potter
Cemetery: Pine View