Jeckel, Glen Charles ' I'
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Glen Charles Jeckel Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/15/2020 79 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Pending
0 � Natural Cause �Accident �Homicide Suicide �Undetermined �
W C.) Circumstances Investigation
W Medical Certifier Name Title
CI Sean Bain MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 472
Burial Date Cemetery,Crematory or Facility Name
10/19/2020 Pine View Crematory
0 Entombment Address
0 Cremation Queensbury Town,New York
Donation
ZZ Removal Date Place Removed
and/or and/or Held
W Hold Address
0
a. Date Point of
(/) L j Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
a Address
IIt
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/18/2020 Registrar of Vital Statistics ?o6e,1, utrrewCurtsr(E/ctronicafSigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Pill Date of Disposition ill 116 Place of Disposition
(a
W
CC (section) • (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises t.9 �Or,ntl�
Z (plea print) ,.�/�
W ,��tt,,��
Signature Title �'"' trf0C
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 0 1 4 1 2'
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#