Goodman Sr, Warren f 1
lis
NEW YORK STATE DEPARTMENT OF HEALTH �t/
Vital Records Section Burial - Transit Permit
: Name First Middle Last Sex
� • Warren William Goodman,Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
:.:: February 27, 2016 83 War or Dates Korean
iPlace of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 227 Fifth St.
0 Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Doug Dennett MD
'1i: Address
:
"r•1 84 Broad St.Glens Falls,NY
:}rra Death Certificate Filed District Number RziEtter Number
__ City, Town or Village Queensbury 5657
❑Burial Date Cemetery or Crematory
❑Entombment March 1, 2016 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
E Hold
Cl)
0 Date Point of
yI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
�;ti:; Permit Issued to Registration Number
;ti: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
::r; Address
:ti:�� 407 Bay Road, Queensbury, NY 12804 _
r Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
�r J Permission is hereby granted to dispose of the human r ains described above as indicated.
r Date Issued 1 I a-E)1 (fl Registrar of Vital Statistics Q. `--n ,
•.? (signature) ��
::: District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition 3 J'i1i,, Place of Disposition gni ,(-/ Crclw,Citpt•y,—
w (address)
W
CO
CL 41i.ltual,....(lotnumber) (grave number)
(section)ap Name of Sexton or Person in Charge of Premises t,n+,ll�''Z p ase print)
Signature l�c/l. 2 Title nu,4 371L
(over)
DOH-1555(02/2004)