O'Connor, James NEW YORK STATE DEPARTMENT OF HEALTH - 39�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James _ Thomas O'Connor Male _
Date of Death Age - If Veteran of U.S. Armed Forces,
5/12/2018 78 War or Dates n/a
Place of Death Hospital, Institution or
ZCity, Town or Village Queensbury Street Address 44 Willowbrook Road,Apt 306
0 Manner of Death C Natural Cause ElAccident n Homicide n Suicide n i Undetermined l Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Dr Gerald Abess,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury, NY 5657 LP
❑Burial Date Cemetery or Crematory
May 15,2018 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
2 and/or Address
H Hold
CO Date Point of
O.
• Transportation Shipment
p by Common Destination
Carrier
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 Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
IX
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5- (y" -0D0)g Registrar of Vital Statistics la-c/S-- ' ..e Q.Q
(signature)
District Number lv 5-1 Place Q u e. e n S tokirl
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I
Z
W Date of Disposition 5iis 1il Place of Disposition ?,.1L.,.
2 (address)
W
IX
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of P mises �..1 5....,Iir
Z (pl ase print)
W
Signature Title CaEmit1U'L
(over)
DOH-1555(02/2004)