Demas, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First l Middle Last Sex
John George Demas Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 12,2011 78 War or Dates
ii Place of Death Hospital, Institution or
City, Town or Village queensbury Street Address 65 Meadow Drive
Manner of Death a Natural Cause n Accident L Homicide n Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier "?cl � ( et U\--P ti 0 Title
61, 1- �,
Death Certificate Filed ' District Number Register Number
;;. City, Town or Village Queensbury, 5657 g'2_
❑Burial Date Cemetery or Crematory
Entombment Address
15, 2011 Pine View Crematory
CI Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
z C Removal and/or Held
and/or Address
H Hold
N_
0 Date Point of
yC Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
EReinterment Date Cemetery Address
-*if Permit Issued to Registration Number '': ,.
Name of Funeral Home Sullivan-Minahan& Potter 01646
:: Address
407 Bay Road,Queensbury,NY 12804
iiiii Name of Funeral Firm Making Disposition or to Whom
t;:;:j Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ins described abov s indicated.
Date Issued c - ►6-dow Registrar of Vital Statistics . b X.
(signature)
• District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 15-15 -2.011 Place of Disposition _ ilk he V t'-e ) Cr �c r i�7►`Vi
2 (address)
W
co
re
0 i ( , (lot nwther) (grave number)
p Name of Sexton or Person in Charge Premises i owi p 7 y t/e
Ple
Z ---�~ �� (please print)
Signature t� �1 /7! Title CJ'c rc40k^y 0 'c1
—J (over)
DOH-1555(02/2004)