Callaghan, Francis Thomas A. It A g� )
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Francis Thomas Callaghan Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/17/2019 89 Years War or Dates Army
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 32 Maple Drive,Queensbury Town,New York 12804
p Mannerof Death 93 Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined Pending
V Circumstances Investigation
W Medical Certifier Name Title
Anne Evans DO
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 191
Burial Date Cemetery,Crematory or Facility Name
12/20/2019 Pine View Crematory
Entombment Address
0 Cremation Queensbury,New York
Donation
Z Removal Date Place Removed
and/or Held
and/or
I
N Hold Address
O
IL Date Point of
N ❑Transportation
p 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
E.. Remains are Shipped,If Other than Above
„3E Address
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/19/2019 Registrar of Vital Statistics Carohnex�garde 0-,Aer(E&rtronrcalySigned/
(signature/
I
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
� I
WDate of Disposition _�/9 Place of Disposition ,4 ,' t'r �-
ddress)
W
N (section) (lot number) (grave number)
8 Name of Sexton or Person in Charge of P mises
Z (Please print)
W Signature Title 4
DOH-1555(07/18)p 1 of z
i
Public Health Law Sec. 4145(2b) 013166
Receipt
Human remains of delivered on , 20
if
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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