VanOrman, Halsey NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vita4Records Section
Nand First Middle Last Sex
• Halsey Van Orman Male
Date of Death Age If Veteran of U.S. Armed Forces,
• December 14, 2014 94 War or Dates
Place of Death Hospital, Institution or
: r
City, Town or Village Glens Falls, NY Street Address The Pines of Glens Falls
ct Manner of Death in Natural Cause n Accident n Homicide n Suicide n Undetermined Pending
t Circumstances Investigation
Medical Certifier Name Title
• Daniel Larson,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Regis rNumber
City, Town or Village Glens Falls,NY 5601 —1 a
El Burial Date Cemetery or Crematory
December 18, 2014 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road Queensbury, NY
Date Place Removed
Z Removal and/or Held
and/or Address
E Hold
cn
O Date Point of
NLi Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
11
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
l- Remains are Shipped, If Other than Above
Address
til
X.
Permission is hereby granted to dispose of the human remains escribed bove as in. - .
Date Issued / Registrar of Vital Statistics , L c71 C_
(signature)
• District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition /4/8//L( Place of Disposition 2,f 0LatItoc, £. ...c &..1 Li /)fO
2 (address) "7
ccnn uG�t2CQ i. �l 0 -
re (sects (lot number) (grave number)
pName of e or Person in Charge of Premises A/ux�r E �. .OG>7�rr--
Z r (pçintW Signat i(�jyt,c ? -Q Titl Y f� 't
(over)
DOH-1555(02/2004)