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Fitzgerald, Donna S LiF # 23c NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donna S Fitzgerald Female Date of Death Age If Veteran of U.S.Armed Forces, 03/10/2023 89 Years War or Dates i_ Place of Death Hospital,Institution or W City,Town or Village Moreau Town Street Address 192 Lamplighter Acers, Moreau Town, New York 12828 O Manner of Death El Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending UJ U Circumstances Investigation U! Medical Certifier Name Title Marissa Chaffee PA Address 3 Iron gate Center,Glens Falls,New York 12801 DeaRth Certificate Filed Town Of Moreau District Number Register Number City,Town or Village 4562 13 Burial Date Cemetery,Crematory or Facility Name 03/13/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held E= Hold Address N 0 d Date Point of U)ElTransportation Shipment p by Common Carrier Destination Date Cemetery Address Disinterment 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 aAddress CC UJ C' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/13/2023 Registrar of Vital Statistics cBrencla 2futter(ECectronicafy 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— -►� Z Date of Disposition 3)IS It Place of Disposition ,�,v— AI r.. UI (address) UJ NCC (section) f (lot number) (grave number) SName of Sexton or Person in C of Premise fi 4, t" +t Z (p ase print) Title e W Signature 1� DOH-1555(07/18)p 1 of 2 4 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#