Reynolds, Michele A it 032
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michele A.Reynolds Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/06/2022 63 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for RehabHifation and Nursing
O Mannerof Death ID Natural Cause DAccident El Homicide OSuicide ❑Undetermine0 ❑Pending
W Circumstanc Investigation
W Medical Certifier Name Title
O Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed Town aQueenebury District Number gister Number
Cit ,Town or Village1
5657T
Burial Date Cemetery,Crematory or Facility Name
081
091
2022 Pine View Crematory
Entombment Address
aCremation Queensbury Town,New York
Donation
QRemoval Date Place Removed
p and/or and/or Held
N Hold Address
0
t�a. Date Point of
Tran sportation
0 by Common Shipment
Carrier Destination
Oisi nterment
Date Cemetery Address
Date Cemetery Address
ElReinterment
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 Otherthan Above
a Address
Q
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/08/2022 Registrar of Vital Statistics Carol:nu.7ihlsgart4 earier(*EGctttm Sigrid}
/signature/
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Q('I 12Z Place of Disposition "IA< � 1.Vt dit__
2 (add-ess/
W
CC N (section) (lot number) r (grebe number)
4-it' L_ f+
8 Name of Sexton or Person in Charge of Pre 'see M
Z / ese print)
fL Signature 2/'
Title CfCre AirE
DOH 1555(07/18)p i of 2
I
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#