Reynolds, Walter NEW YORK STATE DEPARTMENT OF HEALTH
t* Vita1Records Section Burial - Transit Permit
?`,. Name First Middle Last Sex
f% Walter John Reynolds Male
'"% Date of Death Age If Veteran of U.S. Armed Forces,
<r
-f' June 15,2016 95 War or Dates World War II
f/�
f, Place of Death Hospital, Institution or
City, Town or Village Queensbury, NY Street Address 17 Northrup Drive
Manner of Death ❑Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Christopher Hoy MD
i' Address
f` < 161 Carey Rd.Queensbury,NY
�r Death C icate Filed`'-' 1 District Number Re ister Number
J„�' / �,( y
City Town o Village k ) c,.,�-,iTh� ,;=L ,-CSC 'Th ) I
❑X Buri .---_-' Date Cemetery or Crematory
June 16, 2016 i Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road Queensbury, Queensbury, NY 12804
Date Place Removed
ZO C Removal and/or Held
and/or Address
H Hold
N
O Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'r Permit Issued to Registration Number
.:r Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
`. Address
0 407 Bay Road, Queensbury, NY 12804
"' Name of Funeral Firm Making Disposition or to Whom
1` ' Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued LQ t I 1 IdO i (‘)Registrar of Vital Statistics J c----..._ C-( CIA (L-___
s „ .- ---� (signature)
%' District Number ��� Place ( �-r-, L-5-
I certify that the remains of the decedent identified above were disposed of in accordance is permit on:
W Date of Disposition 6/1 8/1 6 Place of Disposition Pine View Cemetery, Queensbury, NY
(address)
ILI
VV) Hudson 3 230 3
W (section) (lot number) (grave number)
pName of Sext or Person in Charge of Premises Connie L. Goedert
Z �D (please print)
w Signature "- e Title Cemetery Superintendent
(over)
DOH-1555(02/2004)