Reynolds, Matthew t I.
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12
NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
is Name First Middle Last Sex
Matthew Elmer Reynolds MALE
Date of Death Age If Veteran of U.S. Armed Forces,
9/18/2018 46 War or Dates YES ARMY
Place of Death Hospital, Institution or Roadway Inn Room 242,
ZCity, Town or Village Ulster Street Address 239 Forest Hill Dr.
ciManner of Death❑Natural Cause 0 Accident Homicide Z Suicide Undetermined ❑Pending
Circumstances Investigation
at Medical Certifier Name Title
James Kurt Grovenburg ME
Address
238 Golden Hill Lane Kingston, NY 12401
Death Certificate Filed District Number RegisterIN'mber
City, Town or Village Ulster 5567 IU
❑Burial Date Cemetery or Crematory
9/24/2018 Pine View Crematory
:ii❑Entombment Address
iig®Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
V Date Point of
Ili
trA❑Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
m Lii ::Q Reinterment Date Cemetery Address
$ Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
Lu
Permission is hereby granted to dispose of the human re ains described a v as indicated.
Date Issued a-ao C 1C1 Registrar of Vital Statistics
(sighature)
gi District Number 5567 Place Town of Ulster
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Date of Disposition 11 Z4 1111 Place of Disposition o li... lt�
2 (address)
ta
;A
Cr (section) II(dot number) S (grave number)
pName of Sexton or Person i.p Charge of Premises C/,n, �ir- to
(phase print) •
14 Signature / +�- Title (I/C)1 wL
(over)
DOH-1555 (02/2004)