Selleck, Jeffrey -
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jeffrey R. Selleck Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/16/2017 26 War or Dates NA
,„ Place of Death Hospital, Institution or
Z City, Town or Village Town of Bolton,NY Street Address Edgecomb Pond/Reservoir,Town of Bolton,NY
aManner of Death ❑Natural Cause I 1 Accident ❑Homicide C Suicide ❑ l Undetermined I Pending
111 Circumstances Investigation
gi Medical Certifier Name Title
O Michael Sikirica MD
Address
50 Broad St.Waterford,NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village Town of Bolton,NY ���O
®Burial Date Cemetery or Crematory
❑Entombment December 21, 2017 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
H Hold
rn
O Date Point of
Wn Transportation Shipment
p by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
417 Bay Rd. Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
ti'mk Remains are Shipped, If Other than Above
Address
W'
A--
, Permission is hereb granted to dispose of the human remains_descr'bed a ove as indicated.
Date Issued I2-t i`S 1 ) Registrar of Vital Statistics -C. r-
(signature) /1
District Number .54,50 Place b()14 o N
F I certify that the remains of the decedent identified above were disposed of in ac rdance with this permit on:
�Z &I/441A_ Ed
' Date of Disposition /2�71/i Place of Disposition 2/ ,�,�,r J
2 / (address)
Ill
01.E 13
s ion) (lot number) (grave number)
p0 Name of on or Perso in Charge of Premise �N•IU75 L. ( p-ar"
Z g ( ease print) ,9 ,
W Title 24 Si natur
(over)
DOH-1555(02/2004)