Arnstein, Theodore A , 'R,NEW YORK STATE DEPARTMENT OF HEALTH S�b
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
la Theodore Arnstein Male
r=i.`: Date of Death Age If Veteran of U.S. Armed Forces,
r' July 14, 2017 94 War or Dates
.._...._. Place of Death Hospital, Institution or
lit City, Town or Village Glens Falls Street Address Glens Falls Hospital
#lst Manner of Death Undetermined Pending
❑X Natural Cause �Accident �Homicide n Suicide
itt Circumstances Investigation
Medical Certifier Name Title
zizi Sadra A -Ghannad
Address
'' 100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number RetE Number
,l:> City, Town or Village Glens Falls 5601 1
❑Burial Date Cemetery or Crematory
July 17, 2017 Pine View Crematorium
❑Entombment Address
El Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
z ❑Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
1.11Permit Issued to Registration Number
..f:<: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Mii Address
:ia 407 Bay Road, Queensbury, NY 12804
>': Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
E
::; Permission is hereby granted to dispose of the human remain described •bove as i dice ed.
ini Date Issued 7 J 1/ Q%I Registrar of Vital Statistics i fir _ ".441, // Al /AN'
(sig ature)
:: District Number 5601 Place Glens Falls
{
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 7)Ih II) Place of Disposition fiu �-�� , gyeasioN.,
W (address)
0 (section) �°t number) (grave number)
Z Name of Sexton or Person in Charg of Premises /ttjf J .{
Z /J� (plea a print)
Signature �;�( Title ((
(over)
DOH-1555(02/2004)