Cushing, Jr. Paul NEW YORK STATE DEPARTMENT OF HEALTH V
Vital Records Section Burial - Transit Permit
y`, Name First Middle Last Sex
Paul E. Cushing,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 4, 2011 81 War or Dates No
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
US
• Manner of Death I XI Natural Cause Accident I }Homicide Suicide Undetermined Pending
At Circumstances Investigation
gam; Medical Certifier Name Title
David Cunningham Dr.
Address
°''3 Irongate Center,Glens Falls,NY 12801
Death Certificate Filed ' District Number Register Number
7'y City, Town or Village Glens Falls 5601 I ,,,�
❑Burial Date Cemetery or Crematory
January 6, 2011 Pine View Crematorium
Entombment Address
CI Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
O and/or Address
▪ Hold
O Date ! Point of
W Transportation Shipment
p by Common Destination
Carrier
I
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Sullivan Minahan & Potter 01675
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1* Remains are Shipped, If Other than Above
S' Address
t
, Permission is h reby granted to dispose of the human r(Tnains scribed a ve as in mated.
• Date Issued// /20i/ Registrar of Vital Statistics l t
(signature)
District Number 5601 Place Glens Falls / "' 1 /d2 ig/
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
W Date of Disposition .74,,,1�' o ij Place of Disposition - ,r,,rUi,o,, Cr/yr%cc(0 rives
(address)
WCC
(section) (lot numberr (grave number)
- ,
p Name of Sexton or Person in Charge f Premises L4-.s.-,,(lkcr o,aif-
Z t (please print)
W
Signature 1," Title C2(':rye} 0a,
(over)
DOH-1555(02/2004)