McLeod, Ann Butler NEW YORK STATE DEPARTMENT OF HEALTH '- IF . '
I
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Ann Butler McLeod Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/28/2022 90 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
QManner of Death El Natural Cause Accident 0 Homicide Suicide
Undetermined Pending
W
U Circumstances Investigation
G Medical Certifier Name Title
Livana Koznesoff MD
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 1074
Burial Date Cemetery,Crematory or Facility Name
06/01/2022 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
OZ❑Removal Date Place Removed
H and/or and/or Held
N Hold Address
0
O. Date Point of
U)OTransportation
0 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
1— Remains are Shipped,If Other than Above
5" Address
Q
W
Q. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/31/2022 Registrar of Vital Statistics cDanw1eScilrespie(E(ectronicaITySigned)
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition 1 i Place of Disposition F �
W /4 -`
2 (address)
Iii
U)
0 (section/ J
(kg number)i (grave number)
0 Name of Sexton or Person in Charge of Premises " l.�
Z fi (P(ee print)
W Signature Title G relq(
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
s
`
Human remains of % delivered on / , 20
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Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#