Sullivan, J. *
t.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
i Name First Middle Last Sex
J. Craig Sullivan Male
a Date of Death Age If Veteran of U.S. Armed Forces,
A July 8, 2016 75 War or Dates
r I Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
I' Charles Yun
IAddress
102 Park Street,Glens Falls,NY 12801 •
:•
.•. Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 3 i4
0 Burial Date Cemetery or Crematory
July 11, 2016 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road Queensbury, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NI I Transportation Shipment
3 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
. Permit Issued to Registration Number
}A r Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
•: Address
4: 407 Bay Road, Queensbury, NY 12804
r� Name of Funeral Firm Making Disposition or to Whom
IR Remains are Shipped, If Other than Above
Address
rr' Permission is hereby granted to dispose of the human remains desc ibed abov as ' dicated.
,5 Date Issued 7 I t I �lf� Registrar of Vital Statistics ���
�'�
:: :;`` (signature)
1':iS
District Number 5601 Place Glens Falls/V k/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
laDate of Disposition 7/1 1 /1 6 Place of Disposition
Pine View Cemetery, Queensbury, NY
2 (address)
N New Kenesaw Ext. 2 1
W (section) (lot number) (grave number)
QName of or Person in C arge of Premises Connie L. Gee Bert
Z • e (please print)
illSignatu nr�-tc Title Cemetery Superiendent
(over)
DOH-1555(02/2004)