McAvinney, Gerald . i 3 Lj
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gerald F. McAvinney Male
Date of Death Age If Veteran of U.S. Armed Forces,
fA February 15, 2017 83 - War or Dates Korean
Place of Death Hospital, Institution or
. City, Town or Village Queensbury Street Address Warren Center
Manner of Death I( Natural Cause ❑Accident n Homicide n Suicide n Undetermined Pending
Circumstances Investigation
1 Medical Certifier Name Title
2.K Roslyn Socolof
0 Address
Warren Center,Queensbury,NY 12804
0 Death Certificate Filed District Number R ister Number
y City, Town or Village Queensbury 5657
❑Burial Date Cemetery or Crematory
El Entombment February 16, 2017 Pine View Crematorium
Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
F' Hold
N
0 Date Point of
n Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
: *0Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
L 407 Bay Road, Queensbury, NY 12804
r Name of Funeral Firm Making Disposition or to Whom
7,1 Remains are Shipped, If Other than Above
=1 Address
Permission is hereby granted to dispose of the hum�a u ins described ab�v((ee as indiated.
ADate Issued�(gc ) Registrar of Vital Statistics �`^-- ' C. ��J,--.._____.
45
(signature)
4:' District Number 5657 Place Queensbury
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Lil Date of Disposition `7- /�l/7 Place of Disposition i)1�V iC)1 ife_kv �11
/ (address) /
W
r
(section) _ of number) (grave number)
QName of Sexton or P rho in Charge of Premises if- I , e,• � (7A✓n e c-1.4 Q
`Z , (please print)
Signature ./v Title (,�,, :; U e,; ../
(over)
DOH-1555(02/2004)