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Daniels, Edward NEW YORK STATE DEPARTMENT OF HEALTH # IO Vital Records Section Burial - Transit Permit Name First Middle Last # Sex Edward Francis Daniels Male 1 hY Date of Death Age If Veteran of U.S. Armed Forces, May 18,2017 77 War or Dates n/a `t' Place of Death Hospital, Institution or City, Town or Village Moreau Street Address 23 Fernwood Road Manner of Death L2NNatural Cause ❑Accident n Homicide ❑Suicide n Undetermined ]Pending Circumstances Investigation Medical Certifier Na �� 5C-\ :y-8 `"\r Tit Address 1 1 i1^l Death Certificate Filed Dist umber \ Reg!' je�jNumber ` i City, Town or Village Town of Moreau 4562 "'� -I ❑Burial Date Cemetery or Crematory May 25,2017 Pine View Crematorium ❑Entombment Address ©Cremation 51 Quaker Road, Queensbury,NY 12804 Date Place Removed Z ❑Removal and/or Held and/or Address • H Hold Cl) 0 Date Point of N ❑Transportation Shipment p by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address :iiN Permit Issued to Registration Number wii ri Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address Al 407 Bay Road, Queensbury, NY 12804 '" Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address v�. Permission is hereby g anted to dispose of the human remai ibe ove s indicated. > Date Issued [�5'(� �/�Registrar of Vital Statistics G� �l 01. (signature) v,�v: District Number b zo),— Place 0,) / Peqiik /C� /=�'1 fyorp-�(,,� f 8 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition S!YS 11-) Place of Disposition -got tt-' (µr,4I cr;,_ W (address) U) Z (section) ) (lot number) S (grave number) OName of Sexton or Person in Charge of Premises �/�,�; d�111(it Z (plea a print) Signature ZviTitle /74M�Iry (over) DOH-1555(02/2004)