Robertson, Joan A NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Joan A Robertson Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/15/2022 92 Years War or Dates
Place of Death Hospital,Institution or
ill• City,Town or Village Queensbury Town Street Address 286 Cleverdale Road,Queensbury Town,New York 12820
G Manner of Death ❑X Natural Cause Accident El Homicide OSuicide nUndetermined ❑Pending
ILI
Circumstances Investigation
W Medical Certifier Name
Title
O Lauren Dinsmore PA
Address
9 Carey Road,Queensbury Town,New York 12804
DeaHth Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 178
Burial Date Cemetery,Crematory or Facility Name
11/17/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Date Place Removed
0❑Removal and/or Held
II—- and/or
N
- Hold Address
0
Date Point of
U)❑Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Renterment i
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
}- Remains are Shipped,If Other than Above
2 Address
Q
W
to Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/17/2022 Registrar of Vital Statistics Carolinextgar'e Bar6er(Electronicall:y SigneO
(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: A._
I— ` '
Z Date of Disposition mil i I7Z Place of Disposition Y�
W (address)
W
CC (section) (lot number) (grave number)
Name of Sexton or Person in Cha of Premises do1 h-- rrS (pease print)
z
W Signature Title iffnii rat
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) .2. .
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#