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Ross, Michelle F 4 ic±f) Jj-Z51 NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Michelle F.Ross Female Date of Death Age If Veteran of U.S.Armed Forces, 03/15/2023 72 Years War or Dates F. Place of Death Hospital,Institution or City,Town or Village Kingsbury Town Street Address 25 Melony Lane,Kingsbury Town, New York 12839 Manner of Death 0 Natural Cause Accident 0 Homicide 0Suicide Undetermined Pending ✓ Circumstances Investigation OMedical Certifier Name Title David Cunningham MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed Town Of Kingsbury District Number Register Number City,Town or Village 5762 6 Burial Date Cemetery,Crematory or Facility Name .` 03/17/2023 Pine View Crematory Entombment — Address ©Cremation Queensbury,New York ,,,t❑Donation 2 Removal Date Place Removed ,� and/or and/or Held Hold Address 0 U) Transportation Date Point of A by Common Shipment 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 Remains are Shipped,If Other than Above Address 111 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/17/2023 Registrar of Vital Statistics Cynthia Bardin(ECectronicatTy Signed) (signature) District Number 5762 Place Town Of Kingsbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 3 I to I'D Place of Disposition W 2 (address) W CC (section) (lot number) (grave number) Spv,.., 8 Name of Sexton or Person in Charge of Premises - A, 1-....., i}t z . ..1. / /lease print) W Signature Title (17,4rif(192 DOH-1555(07/18)p 1 of 2 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#