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Dineen, William 4779 NEW YORK STATE DEPARTMENT OF AEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex William Patrick Dineen Male Date of Death Age If Veteran of U.S. Armed Forces, ; December 10, 2016 84 War or Dates n/a Place of Death Hospital, Institution or City, Town or Village Queensbury Street Address 18 Fairwood Drive to Manner of Death n Natural Cause I I Accident fl Homicide ri Suicide Undetermined I l Pending W> Circumstances Investigation uk Medical Certifier Name Title © Lynn Keil,PA Address Queensbury,NY Death Certificate Filed District Number Register Number City, Town or Village Queensbury, NY 5657 i(r,0 ❑Burial Date Cemetery or Crematory December 13, 2016 Pine View Crematorium El Entombment Address ©Cremation 51 Quaker Road, Queensbury,NY 12804 Date Place Removed Z Removal and/or Held O and/or Address H Hold CO 0 Date Point of N I j Transportation Shipment p by Common Destination Carrier n Disinterment Date Cemetery Address n Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Road,Queensbury,NY 12804 Name of Funeral Firm Making Disposition or to Whom j Remains are Shipped, If Other than Above Address ta 1 Permission is hereby granted to dispose of the human re ins des ve s indi ated. Date Issued -i -(gyp Registrar of Vital Statistics _ 6- C.c_j_P a (signature District Number 5(Q5"-1 Place ✓ (©(I.5), c Di.P...1 Lj A-k, I certify that the remains of the decedent identified above were • •posed of in accordance w' this p mit on: W Date of Disposition /2 2 i Place of Disposition ?lig_ � I ek) Cr! a' c g (address) W U) 0 (section) (lot number) (grave number) p Name of Sexton or in Charge of Premises k i,a•A C. h.e (please print) W Signature Title 6-'erY7A-4" (over) DOH-1555(02/2004)