Barrett, Earl "IR
34
NEW YORK STATE DEPARTMENT OF HEALTH i
Vital Records Section Burial
11 ial - Transit Permit
Name First Middle Last Sex
Earl C. Barrett Male
Date of Death Age 1 If Veteran of U.S. Armed Forces,
July 2, 2011 63 War or Dates
b.- Place of Death Hospital, Institution or
I City, Town or Village South Glens Falls Street Address 212 Main Street Apt 2
to Manner of Death I XI Natural Cause n Accident Homicide Suicide Undetermined n Pending
Circumstances Investigation
# Medical Certifier Name Title
0 Michael Sikirica,Coroner
Address
Albany,NY
Death Certificate Filed District Number Register Number
City, Town or Village South Glens Falls,NY
❑Burial Date Cemetery or Crematory
❑Entombment July 5, 2011 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury, NY 12801
Date Place Removed
ZZ n Removal j and/or Held
and/or Address
H Hold
N
O Date Point of
co0.
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
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
i., Remains are Shipped, If Other than Above
• Address
Permission is hereby granted to dispose of the human remain escribed above as indicated.
Date Issued Q�'QS1 � Registrar of Vital Statistics � L_ /Je
_ (signature)
I-0 -District Number 2 7 Place South Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /�
w Date of Disposition 1"1-t1 Place of Disposition • i,i��t, i (.,t'�^'*aiortt.oA.
W (address)
Cl)
CZ (section) 1 4 of number (grave number)
ap Name of Sexton or Person in Charge o Premises ` c,y ,r vIM1-1-
Z (please print)
W
Signature AL Title Lerjhi,-�
(over)
DOH-1555(02/2004)