Breen, John NEW YORK STATE DEPARTMENT OF HEALTH if
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Timothy Breen Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 20, 2016 67 War or Dates
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 Homicide Suicide Undetermined I-I Pending
Circumstances Investigation
w Medical Certifier Name Title
O John Stoutenburg,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Registeer
City, Town or Village Glens Falls, NY 5601
❑Burial Date Cemetery or Crematory
January 25, 2016 Pine View Crematorium
❑Entombment Address
Cremation Quaker Road,Queensbury, NY 12804
Date Place Removed
O I I Removal and/or Held
and/or Address
Hold
O Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
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
i- Remains are Shipped, If Other than Above
• Address
OC
LU
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued . I 2-24i 6 Registrar of Vital Statistics LA) c .&i t_. UL)
(signs re)
District Number 560 1 Place 6 (QA/kS To, \\S
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition J /2j 'ft, Place of Disposition EKOti.N ((mil'aro—
W (address)
N
(section) (lot num r) (grave number)
QName of Sexton or Person in Charge of remises r., lr1,1rl1+)
Z (please print)
Lu
Signature Title receirtal
(over)
DOH-1555(02/2004)