Guillery, Arthur NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Arthur Phillip Guillery Male
Date of Death Age If Veteran of U.S.Armed Forces,
May 21,2006 52 War or Dates
Place of Death Hospital, Institution or
Z' City, Town or Village Town of Fort Ann Street Address 119 Buttermilk Falls
LU Manner of Death X Natural Cause ElAccident ❑ Homicide ❑ Suicide ElUndetermined ❑ Pending
Circumstances Investigation
j Medical Certifier Name Title
W Michael Angiolillo,Coroner
Address
Whitehall,NY
Death Certificate Filed District Numbe Register Number
City, Town or Village Fort Ann,NY ,5- .5 11
0 Burial Date Cemetery or rematory
5/23/2006 Pine View Crematorium
❑ Entombment Address
❑X Cremation Queensbury,NY
Date Place Removed
z ❑ Removal and/or Held
p and/or Address
1: Hold
aN Date Point of
❑ Transportation Shipment
N by Common Destination
3 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01682
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
A.
IX
W
p. Permission is hereby granted to dispose of the human remai described abov s i dicated.
Date Issued :5--02/;�00fo Registrar of Vital Statistics
( • a ure)
District Number 5 1,5Y Place Fort Ann,NY / 52 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 5 I Z S A-3 L Place of Disposition 'eln r v Lit, ( r ---j c.; r i a ,---
LLI
(address)
w
NCL (section) (lot number) (grave number)
G0 'l Name of Sexton or Person in Charge of Premises ( �'� ��=tii icy IT
Z Jto i (please print)
W Signature I f' V //� �.:A Title CI r* I'r-
DOH-1555 (02/2004) (over)