Nolan, Jeanne H NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jeanne H Nolan Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/17/2023 98 Years War or Dates
i,., Place of Death Hospital,Institution or
WCity,Town or Village Moreau Town Street Address 198 Bluebird Road,Moreau Town,New York 12828
0 Manner of Death ❑X Natural Cause Accident ❑Homicide 0Suicide Undetermined ri Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Anne Evans DO
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 4
Burial Date Cemetery,Crematory or Facility Name
01/19/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
O❑Removal Date Place Removed
and/or and/or Held
NHold Address
0
O. Date Point of
(I)❑Transportation Shipment
5 by Common
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
g Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/19/2023 Registrar of Vital Statistics Leeann McCabe(ECectronica((y Signed)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— y^� /J,�-
Z Date of Disposition 1120 I Place of Disposition r.IL �'f�
LU (address)
W
O (section) /�� (lotnumber) �^I��� (grave number)
0 Name of Sexton or Person in Charge of Premises �G/ aLse riot/ 1\
P
W Signature L _ �� ` Title ! 7,6/11OD
DOH-1555(07/18)p i of 2
4.
ry � 1
..:. 61 5
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#