Kahn, Jean It ITS
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Jean Kahn Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/17/2022 98 Years War or Dates
f.. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls
Street Address Glens Falls Hospital
o Manner of Death El Natural Cause Accident Homicide Suicide
pJ ❑Undetermined ❑Pending
Circumstances Investigation
G• Medical Certifier Name Title
Anne Evans DO
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 326
■Burial Date Cemetery,Crematory or Facility Name
06/21/2022 Pine View Crematory
1.1 Entombment Address
)Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
H and/or and/or Held
N Hold Address
0
0- Date Point of
(I) Transportation
El 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
2 Address
CC
W
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/21/2022 Registrar of Vital Statistics Megan Noliin(ECectronica1Cy Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Dated Disposition 4,-zz-zD,ZZ Place of Disp •ion T foe (),&> Gre-niarc4z) tt-l�
(address) ..
W
(section) r)�/ (lot num (grave number)
CC
Name of Sexton or Person in Charge Premi s f /NO� L0 DOc4
(please print)
W Title Ote7;5
Signature
DOH-i555 lolhal p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of. delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#