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Emery, Samantha Wynn
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit ' Bureau of Vital Records Name First Middle Last Sex Samantha Wynn Emery Female Date of Death Age If Veteran of U.S.Armed Forces, 09/24/2023 36 Years War or Dates F,. Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital W Manner of Death ❑X Natural Cause Accident 0 Homicide 0Suicide Undetermined Pending Circumstances Investigation 0 Medical Certifier Name Title Sean Bain MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 444 Burial Date Cemetery,Crematory or Facility Name 09/27/2023 Pine View Crematory Entombment Address ©Cremation Queensbury,New York Donation ZO❑Removal Date Place Removed and/or and/or Held Hold Address O O. Date Point of V) Transportation S 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 2 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/27/2023 Registrar of Vital Statistics Megan Wolin(ECectronicalfySigned) (signature) District Number 5601 Place City Of Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition q 121 I 13 Place of Disposition 1I TGLIJ CL Utz 2 (address) W CC N (section) /� (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises Y !ease print) IU 12 Signature Title L � � DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 t Pine View Cemetery Representing the funeral home named on burial peanit Official Funeral Directors Reg.or License#