Isaacman, Nathaniel NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
4,
;, Name First Middle Last Sex
Nathaniel Ned Isaacman Male
Date of Death Age If Veteran of U.S. Armed Forces,
• ' June 28, 2012 95 War or Dates
• Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide 1-1 Undetermined Pending
Circumstances Investigation
S, Medical Certifier Name Title
Amy Hogan Moulton,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
f City, Town or Village Glens Falls,NY 5601 30 9
❑Burial Date Cemetery or Crematory
11
Entombment July 2, 2012 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N ❑Transportation Shipment
a 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
• Remains are Shipped, If Other than Above
Address
ak
Permission is hereby granted to dispose of the human remains described above as indicated.
P >
Date Issued L ) 2q 1 j 2-Registrar of Vital Statistics Li3C A.I e-O__ W
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ui Date of Disposition 7/1 2/1 2 Place of Disposition Pine View Cemetery
W (address)
W Adirondack 12 1
(section) (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises Michael Genier
Z 91
(please print)
W Signature _ .QAnn..t.,V Title super; n1- ndent
(over)
DOH-1555(02/2004)