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Dumas. Floyd J. NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Floyd J.Dumas I Male Date of Death Age If Veteran of U.S.Armed Forces, 05/19/2020 100 Years War or Dates 1942-1945 Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 5 Thomas Street,Queensbury Town, New York 12804 p Manner of Death �Natural Cause ❑Accident ❑Homicide Suicide Undetermined Pending W Circumstances Investigation 0 W Medical Certifier Name Title 0 Sharon Shannon NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 108 ©Burial Date Cemetery,Crematory or Facility Name 05/22/2020 Pine View Cemetery Entombment Address ❑Cremation Queensbury Town,New York Donation z Removal Date Place Removed and/or and/or Held ~ Hold Address N IL Date Point of N ❑Transportation Shipment p by Common 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 W I' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/21/2020 Registrar of Vital Statistics CaroCt-Yfifdegarde Bader(Electronwad Synerl� (signature) 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: H W Date of Disposition 5/1 9/2 0 2 0 Place of Disposition 21 Quaker Rd Queensbury, NY 12804 (address) W Erie 47D 1 N (section) (lot number) (grave number) IIr Name of Sexton or Person in Charge of Connie (please print) W Signature Title Superintendent DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 010384 Receipt Human remains of <.. J _, a -,.y, �a delivered on ``' , 20 r, `: { A� Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# DUMAS NAME Floyd J. Dumas Age: 100 Lot Owner: Floyd & Vivan Dumas Lot# Erie 47 D Grave# 1 Case: Concrete Died: 5/19/2020 IntV22/2020 Funeral Home: Singleton , Sullivan, Potter Cemetery: Pine View