Dawson, Joseph —
b.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joseph Martin Dawson Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 21, 2017 85 War or Dates 53-57
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 44 Willowbrook Road, Apt 312
Manner of Death Undetermined Pending
u Natural Cause ❑Accident ❑Homicide ❑Suicide n
Circumstances Investigation
Medical Certifier Name Title
Robert Reeves,MD
Address
Glens Falls,NY 12801
Death Certificate Filed District Number is er Number
City, Town or Village Queensbury, NY 5657
®Burial Date Cemetery or Crematory
July 27,2017 Pine View Cemetery
❑Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
•
Renterment Date Cemetery Address
' Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
iRemains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the hum n remains describ dl above as indicated.
Date Issued\-'--t\O fl Registrar of Vital Statistic l.. C NI--Li—..�
1�-)
(signature)
District Numbe 1 ) Place t 0 of- Luz.
I certify that the remains of the decedent identified above were disposed of in Arnce with this permit on:
WDate of Disposition Place of Disposition
2 (address)
W
(I)
0 (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises
Z (please print)
W Signature Title
(over)
DOH-1555(02/2004)