French Sr., John NEW YORR-STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
o' Name First Middle Last Sex
John Henry French,Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
-`:: October 2, 2014 86 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 11 Lynn Ave
ig Manner of Death g Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
121 Daniel Sooriabalan,MD
Address
•Y I Queensbury,NY
Death Certificate Filed District Number Rigister Number
__• City, Town or Village Queensbury,NY 5657 c L
II Burial Date Cemetery or Crematory
October 4,2014 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F_ Hold
U)
O Date Point of
NTransportation Shipment
p' by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment 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
i,:;:; Remains are Shipped, If Other than Above
Address
at▪ :; Permission is hereby granted to dispose of the human remains describe above as indicated.
Date Issued i(.)` ,) / Registrar of Vital Statistics -----
—
.;`$ (signature)� v
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ttu• Date of Disposition Place of Disposition Pine View Cemttery
(address)
to Abenaki 6C 1
N
Et (section) (lot number) (grave number)
CName of Sexton or Person in Charge of Premises Connie L. Goedert.
Z' (please print)
W g ALdtx _- CLL./ Superintend€nt
Si nature �z Title
(over)
DOH-1555(02/2004)