Fisher, Forrest •
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
C Vital Records Section
Name First Middle Last Sex
Forrest W. Fisher Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 27, 2015 85 War or Dates Army
i,.., Place of Death Hospital, Institution or
Z City, Town or Village Queensbury, NY Street Address Stanton Nursing & Rehab Centre
wp Manner of Death in Natural Cause Accident ❑Homicide Suicide n Undetermined Pending
it1 Circumstances Investigation
i" Medical Certifier Name Title
O Suzanne Blood,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657 id
❑R Burial Date Cemetery or Crematory
January 31,2015 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
= Hold
co
O Date Point of
5 ❑Transportation 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
Remains are Shipped, If Other than Above
IAddress
W;
ti, Permission is hereby granted to dispose of the humairli inp de ii 3e -d - •ove • indicated.
Date Issued 1-c�G1-15 Registrar of Vital Statistic , (:li II
(si.F u -)
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:
W Date of Disposition 1 /31 /201 glace of Disposition 21 Quaker Road, Queensbury, NY 1 2804
2 (address)
N Uncas 3R1 A 2
0 (section) (lot number) (grave number)
p Name of S �on or Person in Charge of Premises Conn i P Goed.Prt
Z (please print)
W
Signatu �.( .e Title Cemetery Superintendent
J
(over)
DOH-1555(02/2004)