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Sullivan, John NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex John Frederick Sullivan Male Date of Death Age If Veteran of U.S. Armed Forces, 10/18/2017 87 Years War or Dates I- Place of Death Hospital, Institution or City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc p Manner of Death©Natural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending W Circumstances Investigation W'' Medical Certifier Name Title C) Philip Gara MD Address „ 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City, Town or Village Fort Edward 5755 45 ❑Burial Date Cemetery or Crematory 10/20/2017 Pine View Crematorium ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed Z❑Removal and/or Held and/or Address H Hold U) O Date Point of 0❑Transportation Shipment O by Common Destination Carrier ID Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address 3, Permit Issued to Registration Number ,, Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Stpo Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped, If Other than Above 2 Address f LU d Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/19/2017 Registrar of Vital Statistics Aimee&ltakoney 'ErectronicalrySigned (signature) District Number 5755 Place Fort Edward, New York F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z LU Date of Disposition AJ 73 j p(1 Place of Disposition it l,.r C n 4c-./ W (address) CO (section) /'// (lot number) (grave number) pName of Sexton or Person in Charge of Pre ises 14,3V) r" i imAtt- z ( ease print) • Signature "`J�' Title G�icre� (over) DOH-1555 (02/2004)