Sousie, Randy NEW YORK STATE DEPARTMENT OF HEALTH c , Z33
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
n Randy J Sousie Male
r:: Date of Death Age If Veteran of U.S. Armed Forces,
March 20, 2016 24 War or Dates
1 P• lace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death
te: Natural Cause X Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
M• edical Certifier Name Title
121
:rr
James North,MD
Address
:: 100 Broad Street,Glens Falls,NY 12801
r.::. Death Certificate Filed District Number Register Number.
City, Town or Village Glens Falls 5601 1
❑Burial Date Cemetery or Crematory
❑Entombment March 25, 2016 Pine View Crematorium
Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
I' Hold
N
O Date Point of
es 1 1 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
?1 Permit Issued to Registration Number
▪ Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
'▪kr Address
407 Bay Road, Queensbury, NY 12804
:,:: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the human remains descr'bed bo a indicated.
Date Issued d 3/23`ZD66 Registrar of Vital Statistics
(signature)
,fr District Number 5601 Place Glens Falls
•:s
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition 3/30 JJ(, Place of Disposition2t), (ryv►aiX14.._
2 (address)
W
Cl)
Ce (section) t (I t number) (grave number)
pName of Sexton or Person in Charge of Premises (Lr. ,Svi it
`Z f please print)
Signature LI
a Title [f' V
(over)
DOH-1555(02/2004)