Antos, Francis ,
q ,
NEW YORK STATE DEPARTMENT OF HEALTH t i� `
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Francis Antos Male
*47
Date of Death Age If Veteran of U.S. Armed Forces,
11/11/2018 84 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Albany Street Address Albany Medical Center Hospital
Manner of Death Ed Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
,.. Circumstances Investigation
gI Medical Certifier Name Title
Travis Smith DO
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed District Number Register Number
. City, Town or Village Albany 0101 2509
❑Burial Date Cemetery or Crematory
11/13/2018 Pine View Crematory
❑Entombmentit Address
r ®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
3,.. and/or37. Address
Hold
• Date Point of
0 Transportation Shipment
by Common Destination
Carrier
P,e,❑Disinterment Date Cemetery Address
•
4❑Renterment Date Cemetery Address
R Permit Issued to Registration Number
1 Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
F.v-r Address
Permission is hereby granted to dispose of the human remains described above as indicated.
r Date Issued 11/13/2018 Registrar of Vital Statistics DanieffeSGi[(espwOctronica1TySigned)
(signature)
District Number 0101 Place Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition r1)/D sli g Place of Disposition 49
„.q--- L r oh—
(address)
(section)of /1(lot number)f (grave number)
t1L
Name of Sexton or Person in Charge Premises r+ J[,+�{aJ
(pi se print)
4Signature4 Title iturflin RI/L.
(over)
DOH-1555(02/2004)