Slattery,Gary Thomas � 3ZZ
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Gary Thomas Slattery Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/07/2020 79 Years War or Dates 63-67
F Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 14 Heresford Lane,Queensbury Town, New York 12804
13 Mannerof Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Uj V Circumstances Investigation
IU Medical Certifier Name Title
Christopher Mason DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 64
❑Burial Date Cemetery,Crematory or Facility Name
04/09/2020 Pine View Crematory
Entombment Address
RI Cremation Queensbury,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
IL Date Point of
U) ❑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
F. Remains are Shipped,If Other than Above
$ Address
Uj
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/08/2020 Registrar of Vital Statistics CaroCtnexfdegarde B&,Aer(Electroak-llyStgne%
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedentidentified above were disposed of in accordance with this permit on:`1 Date of Disposition 't 1 ZO Place of Disposition f fl--
� (address)
W
N
Q (section) (lot numbers"' (grave number)
gName of Sexton or Person in Charge of P mises n9
z ( se print){'
W Signature Title `
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) J - -
a
Receipt i
1
j
Human remains of delivered on , 20_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# "_