Mattice, Gerald NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
IN Name Eir ald MidOle Web le
';; Date of Death A e If Veteran of U.S. Armed Forces,
02/13/2017 66gyears War or DatesNO
Place of Death Hospital, Institution or
City?przabnge Schenectady Street Address9 North Church St, Schenectady
Manner of Death❑Natural Cause ElAccident ❑Homicide ❑Suicide ri❑Undetermined Pending
;ilk Circumstances Investigation
tit Medical Certifier Name Title
N Balasubramaniam Medical Examiner
AticIrgt t St, Schenectady, N Y 12308
Death Certificate Filed
Schenectad District
istri t Number Register Number
11NityX n tge y 17
"r Burial Date Cemetery or Crematory
02/17/2017 Pine View Cemetery
IN❑Entombment Address
❑Cremation Town Of Queensbury, N Y
Date Place Removed
Z❑Removal and/or Held
and/or Address
t.! Hold
Date Point of
tL Transportation Shipment
C by Common Destination
1111111111 Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
in Permit Issued to Singleton Sullivan Potter Funeral Home F�eg�istration Number
g
Name of Funeral Home
iigiii Add
46,sgay Rd, Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ILI
X.
Permission is hereby granted to dispose of the human remains sq ibed bove in is d.
Date Issued
02/16/2017 t ,
Registrar of Vital Statistics bbb�t 1 , aA,k, r-ild,
s nature)
Mii District Numb01 Place Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
lii Date of Disposition 2/1 7/1 7 Place of Disposition Pine View Cemetery, Queensbury,NY
(address)
ILI
Huron 20J 1
CC (section) (lot number) (grave number)
CI Name of Se n or Person in Charge of Premises Connie L. Goedert
(please print)
in
Signatur l'IL J. Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)