Marshall, Albert € ' 4 if [`7c, ei J
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
A.
Name First Middle Last Sex
Albert H. Marshall Male
`t Date of Death Age If Veteran of U.S. Armed Forces,
f : August 12, 2016 80 War or Dates Army Reserves
: Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death '�I Natural Cause ElAccident n Homicide pi Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier
%1Name Title
Dr.Coppens,MD
Address
`'` Glens Falls,NY
0' Death Certificate Filed District Number Regist7 ber
A.; City, Town or Village Glens Falls,NY 5601
El Burial Date Cemetery or Crematory
August 15, 2016 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
N Hold
N
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
E Disinterment Date Cemetery Address
E Reinterment Date Cemetery Address
e Permit Issued to Registration Number
1Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
"I Name of Funeral Firm Making Disposition or to Whom
I:``< Remains are Ship
ped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains descr' ed bo a i 'cated.
Date Issued 00*G Registrar of Vital Statistics
� (signature)
.a District Number 12,,0/ Place City of Glens Falls,NY 12801
▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z DispositionPlace of Disposition geak... G ,,..W Date of g /� l� p
W (address)
CO
is (section) (lot (grave number)
number) �'
Q Name of Sexton or Person in Charge of Pre ises 4 J,-.41/
W ( print)
Signature Title V—AVVV°
(over)
DOH-1555(02/2004)