Pines, Paul NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
, Paul Andre Pines Male
tz Date of Death Age If Veteran of U.S. Armed Forces,
6/27/2018 77 War or Dates n/a _
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 55 Garfield Street
Manner of Death ❑X Natural Cause 0 Accident Li Homicide ❑Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
x
, John Stoutenburg,MD
Address
Glens Falls,NY
v-. Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 3 }
❑Burial Date , Cemetery or Crematory
Entombment June 29,2018 _ Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address
H Hold
CO
O Date Point of
N ❑Transportation _ Shipment
a by Common Destination
Carrier
Date I Cemetery Address
El Disinterment
n Renterment 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
=mom Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
.
Date Issued (Di Z�120I ' Registrar of Vital Statistics (A
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� (signature)
District Number .60 ) Place 6 is2AA5 re, Mi P y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1 Jt Id Place of Disposition fol./ fr~
W (address)
Cl)
0 (section) pilot number) r (grave number)
p Name of Sexton or Person in Charge of Premises r a...41
Z (please print)
Signature a Title
(over)
DOH-1555(02/2004)