Hermance, Edward N
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
`• " Edward Louis Hermance Male
• Date of Death Age If Veteran of U.S. Armed Forces,
• 06/23/2018 83 Years War or Dates Air Force
it Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ILTNatural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Dean Reali DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
41 City, Town or Village Glens Falls 5601 312
4 ®Burial Date Cemetery or Crematory
06/27/2018 Pine View Cemetery
• ❑Entombment4.0 Address
,,.• .7.❑Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
es and/or Address
., Hold
1
Date Point of
❑Transportation Shipment
by Common Destination
st, Carrier
❑Disinterment
Date Cemetery Address
cv
❑Renterment Date Cemetery Address
k,• Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
r
407 Bay Rd,Queensbury,New York 12804
3 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
F .,
U
7 Permission is hereby granted to dispose of the human remains described above as indicated.
tit
iZit Date Issued 06/25/2018 Registrar of Vital Statistics cRp6ertA Curtis(ECectronica1CySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
in Date of Disposition 6/27/201 (lace of Disposition Pine View Cemetery Queensbury
W (address)
ga Horicon 6—F 1
ig (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Connie Goedert
(please print)
111 0,�, Cemetery Superintendent
Signature � "�-� ��cL�-t Title
(over)
DOH-1555(02/2004)