Healy, Jr. Daniel ~r Ljej
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section 6 , 1, Burial - Transit Permit(
Name First Middle Last Sex
Daniel T. Healy,Jr Male
Date of Death ' Age I If Veteran of U.S. Armed Forces,
November 3, 2011 70 1 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls j Street Address Glens Falls Hospital
AU Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined I 'Pending
W Circumstances Investigation
W Medical Certifier Name Title
C_) a ddre
sl, .Nr,
Death Certificate Filed ` District Number Re t ber
City, Town or Village Glens ,NY 5601
❑Burial Date Cemetery or Crematory
November 7, 2011 Pine View Crematory
❑Entombment Address
111 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
1.= Hold
O Date Point of
NI I 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-Healy Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
kr, Remains are Shipped, If Other than Above
,2 Address
re
US
IN
Permission is hereby granted to dispose of the human remains described a ov as/:pizted.
9
Date Issued Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordanceor with this permit on:
wDateof Disposition i i I 1 Ili Place of Disposition .�,..(1)ti,a c rft cT Id i 0'.
W (address)
co
p0 (section) (lot number) (grave number)
Name of Sexton or Person in Charge f Premises _ hiss �C J 111.44
W (please print)
Signature f _ Title C11t Wiil0�
(over)
DOH-1555(02/2004)