Pollock, Jr. Alfred NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alfred L. Pollock,Jr. Male
• Date of Death Age If Veteran of U.S. Armed Forces,
• July 10,2011 83 War or Dates No
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
ttl
Manner of Death n Natural Cause U Accident ❑Homicide n Suicide p Undetermined Pending
W Circumstances Investigation
Medical Certifier Name Title
P. Paul Backman Dr.
Address
4`: 3767 Main Street,Warrensburg,NY 12885
';' Death Certificate Filed District Number Regi ke Number
• =n City, Town or Village Glens Falls 5601 ��ooJJ�� l
❑Burial Date Cemetery or Crematory
❑Entombment July 12,2011 Pine View Crematorium
Address
0 Cremation 21Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NElTransportation Shipment
aby Common Destination
Carrier
Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
Permit Issued to Registration Num_ber
:-` Name of Funeral Home Singleton-Healy Funeral Home 0/5 y(q
Address
407 Bay Road, Queensbury, NY 12804
• : Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
gi Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued //f 3 / i 1 Registrar of Vital Statistics WDAI-r.e
(si(
:' District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z 1-M-(I i�
W "Date of Disposition k Place of Disposition {r ttJ j CtiTtitotat,�
2 (address)
W
CC (section) (lot nu r) (grave number)
c Name of Sexton or Perso in Charge of Premises (lets-kit r :title+
Z /' (please print)
W Signature C Title Ma oiL-
(over)
DOH-1555(02/2004)