Fitchett, Patricia J NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Patricia J.Fitchett Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/02/2022 82 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Lake Luzerne Town Street Address 2 Tall Pines Drive, Lake Luzerne Town, New York 12846
UJ
p Manner of Death ❑X Natural Cause Accident El Homicide Suicide ❑Undetermined ri Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Christopher Mason DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Lake Luzerne District Number Register Number
City,Town or Village 5656 28
Burial Date Cemetery,Crematory or Facility Name
11/07/2022 Pine View Crematory
Entombment Address
E1Cremation Queensbury,New York
,1=1Donation
ZO❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
O. Date Point of
N Transportation
by Common Shipment
Carrier Destination
111
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
Address
Cr
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/03/2022 Registrar of Vital Statistics Cynthia Sherwood- Signed)
(signature)
District Number 5656 Place Town Of Lake Luzerne
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition I I/gi 72 Place of Disposition -T
11J (address)
W
CC
(section) (lot num (grave number)
O Name of Sexton or Person in Charge of Premises //et--
O (please print)
IL Signature L Title � Mine
�
DOH-1555(07/18)pi of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
1
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#