Williamson, Anna Mae IlUs- It %61-
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ri Name First Middle Last Sex
Anna Mae Wi 1 liams.on Female
Date of Death Age If Veteran of U.S. Armed Forces,
iiiii 10/26/23 83 War or Dates n/a
ti: Place of Death Hospital, Institution or
City, Town or Village Town of Moreau Street Address 530 Selfridge Rd
Manner of Death Natural Cause n Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Wi11iam Parker, MD
Address
9 Carey Road, Queensbury, NY
ti Death Certificate Filed // // District Number Lis�c Z Register Number I
:f City, Town or Village Town or 2 or !Meau -
❑Burial Date Cemetery or Crematory
10/30/23 Pine View Crematory
Entombment Address
Cremation Queensbury, NY
Date Place Removed
Zn Removal and/or Held
and/or Address
14. Hold
uT
0 Date Point of
yn Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
(�Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01 596
'''r• Address
..-.• 407 Bay Road Queensbury, NY 12804
• Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
74• Address
:i
;• :: Permission is hereby granted to dispose of the human remains described above as indicated.
f
;.e Date Issued sc�/3n 1 '?3 Registrar of Vital Statistics c k .\i u.+ `..r Q
. - (
(signature)
'
f: District Number .‹.EA`Z Place row rm
1-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
;AU Date of Disposition 10 131 It3 Place of Disposition ri•rF✓'rC.:,, ! MAN ✓A.._
a (address)
40
iZ (section) (lot number) (grave number)
2 Name of Sexton or Person q h ge of Premises r.J L-- A
Z (pase print)
W
Signature , Title 1f6)1 4 1711e
(over)
DOH-1555(02/2004)
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20 ='
Pine View Cemetery Representing the funeral horpe named burial permit
Official Funeral Directors Reg.or License# •