Ryer, Henry NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Henry Lenington Ryer Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 19, 2016 92 War or Dates US Army
Place of Death Hospital, Institution or
2 City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
p Manner of Death I ni
xI Natural Cause 'Accident n Homicide ❑Suicide n Undetermined Pending
LLll Circumstances Investigation
W Medical Certifier Name Title
G William Cleaver Dr.
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number ��
City, Town or Village Glens Falls, NY 5601 �>
El Burial Date Cemetery or Crematory
January 21, 2016 Pine View Crematorium
❑Entombment Address
ElCremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
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 Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2 Address
re
a. Permission is hereby granted to dispose of the human co—Mains scribedabove as i 4 icate•.
Date Issued 01 .r i/(-0/(, Registrar of Vital Statistics e �� - - C�J'E>
signature)
District Number 5 / Place City of Glens Falls,NY 801
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Dispositionf/ Place of Disposition fo V � ip •-�w Date of 2S )l, p L. �'`^''� l'1
2 (address)
W
Cl)
CL (section) /(lot number (grave(grave number)
O Name of Sexton or Person in Char a of Premises (hlri ,\LNi
Z (pl4as nbt
e prin
Signature d ritttzr- Title filimitE I.
(over)
DOH-1555(02/2004)