Lawton, Jeremy Lee •
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jeremy Lee Lawton Male
Date of Death Age If Veteran of U.S.Armed F,o
10/01/2020 43 Years War or Dates
F,. Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 41 Sugarbush Road,Queensbury Town,New York 12804
UJ
11J Manner of Death ❑X Natural Cause Accident ❑Homicide ❑Suicide ElUndetermined ❑Pending
V Circumstances Investigation
W Medical Certifier Name Title
G Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 186
❑Burial Date Cemetery,Crematory or Facility Name
10/05/2020 Pine View Crematory
0 Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
Z ❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
0
O. Date Point of
U1Li Transportation
jr) by Common Shipment
Carrier Destination
❑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 Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
W
Ct' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/05/2020 Registrar of Vital Statistics Carornexfgarie Bader(Ekctronicall;Signed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition it)/iv I it Place of Dispositions
W
2 (address)
W
Q (section) (lot number) (grave number)
SName of Sexton or Person in Charge of Premis 4A1L Ste►( se print) �.�s�//J�
W Signature s'� Title ( .0�t�f
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 13 I 4 0 71
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#