Combs, Lowell NEW YORK STATE DEPARTMENT OF HEALTH a 3Z0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lowell C Combs Male
Date of Death Age If Veteran of U.S. Armed Forces,
4/13/2018 78 War or Dates
• Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
p' Manner of Death ' Natural Cause n Accident ❑Homicide ❑Suicide -I Undetermined n Pending
u1 Circumstances Investigation
W Medical Certifier Name Title
CI Daniel Way,MD
Address
100 Park Street,Glens falls,NY
,! Death Certificate Filed District Number oI Register Number no
City, Town or Village
❑Burial Date Cemetery or Crematory
April 18, 2018 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
�' Hold
Cl)
O Date Point of
O.
E Transportation Shipment
p by Common Destination
Carrier
Date ' Cemetery Address
I I 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
t Remains are Shipped, If Other than Above
Address
%
0. Permission is hereby granted to dispose of the human r ains described ab 've as indi•ated.
Date Issued c /j k/ 1cJ Registrar of Vital Statistics a'1?.�
(signature)
District Number ,5790 I Place Z) Z2r 577I certify that the remains of the decedent identified above wer disposed of in accordan this permit on:
Z 4
� Date of Disposition NI io lib' Place of Disposition �,��,,,,, [ �
(address)
W
IA
W (section) Not number) (grave number)
pName of Sexton or Person in Charge of Premises t ir,,tik, 5G. rt
IZ (plebse print)
Signature tr Title ftt..45ortilitv
(over)
DOH-1555(02/2004)