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Cleveland, Shirley May . NEW YORKSTATE DEPARTMENT OF HEALTHILLF) ) ri\° Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Shirley May Cleveland Female Date of Death Age If Veteran of U.S.Armed Forces, 10/08/2023 96 Years War or Dates i_ Place of Death Hospital,Institution or W City,Town or Village Moreau Town Street Address 198 Bluebird Road 230, Moreau Town, New York 12803 p▪ Manner of Death ❑X Natural Cause AccidentIII Homicide Suicide 111Undetermined Pending Circumstances Investigation W Medical Certifier Name Title G Charles Yun MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Moreau District Number Register Number City,Town or Village 4562 53 Burial Date Cemetery,Crematory or Facility Name 10/10/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury,New York Donation goRemoval Date Place Removed and/or and/or Held N Hold Address NTransportation Date Point of S by Common Shipment Carrier Destination ODisinterment 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 H Remains are Shipped,If Other than Above 2 Address Q W D. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/10/2023 Registrar of Vital Statistics Brenda Jfutter(E(ectronicaltySigned) (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: Date of Disposition i 0 I IZ 123 Place of Disposition fi J Eti ,, ) Ce1,i J!h 2 (address) W Cl) (section) (lot number/ (grave number) CCS Name of Sexton or Person in Charge of Pr •' s A.4,,,i_. ')�Zease print/ W Signature .4Title (ktofit, DOH-1555(07/18)p id 2 Public Health Law Sec. 4145(2b) 0 I f 3 5 1 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#