Mannix, John l
NEW YORK STATE DEPARTMENT OF HEALTHY 1 l
Vital Records Section Burial - Transit Permit
ini Name First Middle Last Sex
JOHN C. MANNIX Male
Date of Death Age If Veteran of U.S.Armed Forces,
April 30, 2006 74 War or Dates yes US Air Force
44 Place of Death Hospital, Institution or
City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
Manner of Death !ir Natural Cause 0 Accident ❑Homicide D Suicide El Undetermined El Pending
W Circumstances Investigation
tu Medical Certifier Name Title
Dr. Amy Hogan-Moulton, MD
Address
Glens Falls, NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens FAlls, NY 5601 / gvg"
><< OBurial Date Cemetery or Crematory
['EntombmentMay 1 , 2006 Pine View Crematory
in
Address
remation Quaker Rd Queensbury, NY 12804
Date , Place Removed
' ❑Removal and/or Held
and/or Address
F' Hold
it-5 Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
0 Reinterment
Date Cemetery Address
Permit Issued to . Registration Number
Name of Funeral Home Sullivan-Minahan & Potter 01734
Address
407 Bay Rd Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
CC
a` Permission is hereby granted to dispose of the human remains descri i c ted.
Date Issued O(`O/% Registrar of Vital Statistics
�� (signature)
District Number 564 Place7e4 .� ' . 4/
]i::i,,,,
'` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
#-
2
W Date of Disposition 5/3/0(0 Place of Disposition Pin:vLel.. Ct(.r•,lorsw
(address)
W
in
CC (section) C- (lot number) (grave number)
ti Name of Sexton or Person in Charge of Premises r� `f "�'^Ngr
I Q
C (please print)
itit Signature / - Title (ar^�
101-
(over)
DOH-1555 (02/2004)