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Farrell, William Francis
- NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex William Francis Farrell Male Date of Death Age If Veteran of US.Armed Forces, 11/19/2019 79 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Fort Ann Town Street Address 32 Goodman Road,Fort Ann Town,New York 12827 p Manner of Death ©Natural Cause Accident Homicide ❑Suicide ❑Undetermined Pending W Circumstances Investigation WMedical Certifier Name Title Charles Yun MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Albany 8888 10 Burial Date Cemetery,Crematory or Facility Name 11/20/2019 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York ❑Donation z ❑Removal Date Place Removed and/or and/or Held N Hold Address W Date Point Transportation by Common Shipment Carrier Destination 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 Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Otherthan Above Address Permission Is hereby granted to dispose of the human remains described above as Indicated. Date Issued 11/20/2019 Registrar of Vital Statistics P,96ertWGocicero(ECectronicallySigner) (signature/ District Number 8888 Place Albany, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Y! Date of Disposition t/_zi�L9 Place of Disposition (address) W (sertgon) Aotnumber) (grave number) Name of Sexton or Person in Charge of Premises /f't' . , /please print/ W Signature �P Title ire C r DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) . 3 0 9 f Receipt Human remains of delivered on , 20 Pine View Cemetery Representing'.the funeral home named on burial permit Official Funeral Directors Reg.or License#