Alverson, J. NEW YORK STATE DEPARTMENT OF HEALTH 4q26
Vital Records Section �` Burial - Transit Permit
Name First Middle Last Sex
J. Maynard Alverson Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 26,2011 71 War or Dates Yes
I.. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls ! Street Address Glens Falls Hospital
p Manner of Death X Natural Cause Accident n Homicide Suicide [Undetermined Pending
►ii Circumstances Investigation
uuj Medical Certifier Name Title
O Eric Pillemer MD
Address
Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Regist�� er
City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
❑Entombment June 27, 2011 Pine View Crematorium
Address
®Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ '—'and/or Removal and/or Held
Address
H Hold
N
O Date Point of
N Transportation Shipment
p by Common Destination
_ Carrier
n 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
I* Remains are Shipped, If Other than Above
:Z Address
,W
0- Permission is hereby ranted to dispose of the human remains escribed ab ye as indic ed.
Date Issued ('�(a ,�� 1 i' Registrar of Vital Statistics O-e_e ;27-c
(sig ature
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:
WDate of Disposition b-Z1-it Place of Disposition Pos.a efet.4ors.w
Ili
(address)
CO
Le (section) (lot nu r) (grave number)
Q Name of Sexton or Person in Charge of Premises Aro c ,qap'`Z `J (please print)
Signature ( Title [Qeo,1i}'
(over)
DOH-1555(02/2004)