Furlong, Daniel 6 . .-.- s .+ # �31
NEW YORK STATE DEPARTMENT OF HEALTH �-�" f.
Vital Records Section Burial - Transit Permit
rName First Middle Last Sex
Daniel R. Furlong Male
,.,
r Date of Death Age If Veteran of U.S. Armed Forces,
>r% October 5,2014 73 War or Dates
-: Place of Death Hospital, Institution or
City, Town or Village Glens Falls, NY Street Address 18 East Tremont Street
Manner of Death n Natural Cause 0 Accident Ei Homicide E Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Glen Anderson,PA
Address
,I, Glens Falls,NY 12801
�t�t
Death Certificate Filed District Number Register Number
f City, Town or Village Glens Falls,NY 5601 (0 L
❑Burial Date Cemetery or Crematory
October 8,2014 Pine View Crematorium
❑Entombment Address
0 Cremation Quaker Road,Queensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
N 0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
MI Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
k' Address
f 407 Bay Road,Queensbury,NY 12804
rr
1 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains desc ' ed ab as/, ated.
?. _ �� ��
fr Date Issued 1Q1p8�7.G/y Registrar of Vital Statistics
g (signs ure)
>f
District Number 5601 Place Glens Falls,NY
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Place of Disposition
2 (address)
W
Cl) (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)