Casperson, William NEW YORK STATE DEPARTMENT OF HEALTH fi `' i Vital Records Section . Burial - Transit Permit
▪ Name First Middle Last Sex
�,,� William Clement Casperson Male
Date of Death Age If Veteran of U.S. Armed Forces,
'7.1March 23, 2016 84 War or Dates Navy
'A: Place of Death
i Hospital, Institution or
City, Town or Village Glens Falls,NY Street Address The Pines Of Glens Falls
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Me ical Certifier Name Title
?� ,^ Addres
. � �5 rJ
r r Death Certificate File District Number Register u er
;_ ; City, Town or Village Glens Falls, NY 5601 /)
❑Burial Date Cemetery or Crematory
March 25, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I ]Removal and/or Held
and/or Address
F Hold
N
0 Date Point of
853 I I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
r,, Permit Issued to Registration Number
R. Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
.; Address
• 407 Bay Road, Queensbury, NY 12804
Niame of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
r
Permission is hereby granted to dispose of the human remains desc 'bed abo e a 'cated.
srr Date Issued D3/Zt/ ZIXL Registrar of Vital Statistics � ,'`
L� -
el�, / (signature)
rr. District Number (0�' Place A`�S /1)V
x:
I certify that the remains of the decedent identified above were disposed of in a accordance with this permit on:
W Date of Disposition 3J/II�� Place of Disposition ,I;nti LJ (f ('tv.
2 (address)
W
N
CL (section) � (lot nu r) (grave number)
QName of Sexton or Person in Charge of Premises l htrijgdg. tis *
Zpplease print)
W Signature f ..%th Title fallow
(over)
DOH-1555(02/2004)