Crosse, John Jr.NEW YORKSTATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial -Transit Permit
Name First Middle Last
Sex
John William Crosse Jr
I Male
Date of Death
Age
If Veteran of U.S. Armed Forces,
10/10/2019
66 Years
War or Dates
Place of Death Hospital, Institution or
WCity,
Town or Village Glens Falls Street Address Glens Falls Hospital
0
Mannerof Death ❑X Natural Cause Accident Homicide 1:1 Suicide � Undetermined � Pending
V
Circumstances Investigation
W
Medical Certifier Name Title
Dean Reali DO
Address
100 Park St, Glens Falls, New York 12801
Death Certificate Filed
District Number
Register Number
City, Town or Village Glens Falls
5601
441
❑ Burial
Date
Cemetery, Crematory or Facility Name
10/15/2019
Pine View Crematorium
Entombment
Cremation
Address
Queensbury Town, New York
Donation
Removal
Date
Place Removed
0
and/or
and/or Held
�-
N
Hold
Address
0
t1
Date
Point of
N
G
❑ 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 orto Whom
I—
Remains are Shipped, If Other than Above
.!�
Address
IM
W
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/11/2019 Registrar of Vital Statistics R96ert/?ndrewCzirru•(Ele<tronwad Syned
(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:
Date of Disposition ja 111 Place of Disposition d (IJ
W
(address/
W
N
Q
(section) #t number) (grave number)
SName
z
W
of Sexton or Person in Charge of Premises L h'
pleas print/
l Title
Signature
DOH-1555 (07/18) p 1 of 2
Public Health Law Sec. 4145(2b) 012596
Receipt
Human remains of delivered on\--' 'i, rb ---,20—
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License #