Cohen, George NEW YORK STATE DEPARTMENT OF HEALTH 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George N. Cohen Male
Date of Death ! Age If Veteran of U.S. Armed Forces,
January 25,2012 1 89 War or Dates
1,,, Place of Death Hospital, Institution or
.Z City, Town or Village Lake George Street Address 479 Goggins Road
pManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
U Circumstances Investigation
w Medical Certifier Name Title
0 r'� N Gt..,
Address l
Death Certificate Filed ; IN.YDistrict Number III Register Number
City, Town or Village Lake George,NY --(,p S
El Burial Date Cemetery or Crematory
January 27, 2012 Shaaray Tefila
❑Entombment Address
El Cremation Media Drive, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NTransportation Shipment
a by Common I Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01596
• Address
= 407 Bay Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1.3 Remains are Shipped, If Other than Above
2 Address
TZ
ALI
Permission is hereby granted to dispose of the human remains escribed above as indicated.
Date Issued l 07-49, Registrar of Vital Statistic ALct, GY.a_
1C-17
(signat re)
•
District Number 37 SJ Place Lake George,NY
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
co
iY (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises
Z (please print)
ui Title
Signature
(over)
DOH-1555(02/2004)