Conway, laura Lee i
el- i 13
DEPARTMENT OF HEALTH -
NEWYORKSTATE Burial Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Laura Lee Conway Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/18/2022 55 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Fort Ann Town Street Address 3 Bean Road,Fort Ann Town,New York 12844
W Manner of Death Undetermined Pending
O n Natural Cause Accident Homicide Suicide
W
L.) Circumstances Investigation
W Medical Certifier Name Title
O Lynn Keil PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Fort Ann District Number Register Number
City,Town or Village 5754 17
RBurial Date Cemetery,Crematory or Facility Name
09/20/2022 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
0Donation
0❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
Date Point of
N)❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
0 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
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/19/2022 Registrar of Vital Statistics Jennifer Jackson(E(ectronicallySigned)
(signature)
District Number 5754 Place Town Of Fort Ann
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition I Ill 12Z Place of Disposition Fn.,�C " 'dt'---
W /address)
W
NCC (section) ,f)
(lot number) (grave number)
O Name of Sexton or Person in Charge• 'remises l
Q /pl se print)
W Signature J/ ice% Title �(t'i�Y�1 „�'
DOH-1555(07/18)p 1 of 2
L r ~ 6 iMa aI c•y
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#