Amter, Paul NEW YORK STATE DEPARTMENT OF HEALTH 3t'
Vital Records Section - Burial - Transit Permit
Name First Middle Last Sex
, Paul Allen Amter Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 11, 2016 62 War or Dates n/a
=% Place of Death Hospital, Institution or
City, Town or Village Glens Falls Manner of Death
Medical Certifier Name
Street Address 425 Glen Street Apt 76
Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Title
I
William Orluk,Coroner
.. Address
Glens Falls,NY
%,,
Death Certificate Filed District Number Register Number
City, Town or Village Falls, NY 5601
❑Burial Date_ Cemetery or Crematory
May 16, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road Ynsbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
Nn Transportation Shipment
as by Common Destination
Carrier
Disinterment Date Cemetery Address
PI Reinterment Date Cemetery Address
'` Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
00 Address
407 Bay Road, Queensbury, NY 12804
ft Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
r
Permission is he eby-granted to dispose of the human r ains described above as in icat d.
kiS Date Issued S . Registrar of Vital Statistics "-'i...1/
r,f
gnnature �f
rid /
Distnct Number Place 1.---
I certify that the remains of the decedent identified above were disposed of in accordance with this erm
:; • it on:
W Date of Disposition 5I/74 Place of Disposition "?tQ V ./ a-
Z (address)
W
Cl)
(section) of nu er) (grave number)
pName of Sexton or Person in Charge of Premises �r1 1M^
Z (please print)
US
Signature �� 4 Title ig1[.
(over)
DOH-1555(02/2004)