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Hoover, Nancy Ann LC,L0---• 1 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Nancy Ann Hoover Female Date of Death Age If Veteran of U.S.Armed Forces, 01/16/2024 72 Years War or Dates E Place of Death Hospital,Institution or City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing p Manner of Death ri Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title Mikram Jafri MD Address 42 Gurney Ln,Queensbury Town,New York 12804 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 8 RBurial Date Cemetery,Crematory or Facility Name 01/17/2024 Pine View Crematory Entombment Address ©Cremation Queensbury,New York Donation 8 Removal Date Place Removed and/or and/or Held F- Hold Address CO 0 O. Date Point of (I) Transportation 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 Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/17/2024 Registrar of Vital Statistics Caroline 1fildegarde Barber(ECectronica1tySigned) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Q W Date of Disposition II iq 174 Place of Disposition t �N.Ev:ic Ct't4ZOterut` (address) W CC CC (section) (lot number) (� (grave number) Name of Sexton or Person in Charge of Premiers "IL tt►„ / e print) ,��, W Signature ( ✓� Title ( iti a 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#