Sherwood, Donald NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald C. Sherwood Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 3, 2017 65 War or Dates n/a
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury, NY Street Address 1260 West Mountain Road Unit 305
E. Manner of Death C Natural Cause I I Accident n Homicide n Suicide ❑Undetermined n Pending
`t;.1 Circumstances Investigation
w Medical Certifier Name Title
O Charles Yun,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657 / ��
®Burial Date Cemetery or Crematory
February 6, 2017 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
Hold
N
O Date Point of
N ['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
Address
Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued(Co, I I Registrar of Vital Statistics Q, CW
(signature)
District Number 1oc n Place �
I certify that the remains of the decedent identified above were disposed of in accor nce w th this permit on:
W Date of Disposition 2/6/201 7 Place of Disposition Pine View Cemetery, Queensbury, NY
W (address)
Cl) Erie 38B 1
O (section) (lot number) (grave number)
p Name of Sext or Person in C of Premi Conn i P T. Goedert
Z (please print)
W
Signature i - Title Cemetery Superintendent
(over)
DOH-1555(02/2004)