Conway, James NEW YORK STATE DEPARTMENT OF HEALTH n I
Vital Records Section ,_ Burial - Transit Permit
: Name First Middle Last Sex
James William Conway Male
rt: ` Date of Death Age If Veteran of U.S. Armed Forces,
April 3, 2015 64 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ❑, Natural Cause pi Accident n Homicide n Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier
iName Title f;. Eric Pillemer,MD
4 Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Registeyumber
City, Town or Village Glens Falls,NY 5601 �/ c2
�❑Burial Date Cemetery or Crematory
April 9, 2015 Pine View Crematorium
III Entombment Address
CI Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
t-" Hold
Cl)
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
111
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
T Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
is ; Address
< 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
s Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I j l 5 Registrar of Vital Statistics LA) QAA.ry\9 �)
(signature)
District Number 5601 Place Glens Falls,NY
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z c7
w Date of Disposition 4/le)I s Place of Disposition �f,,u.4K 4,/ C,or:�-
W (address)
Cl)
CL (section) A (lot number (grave number)
Q Name of Sexton or Person in Charge of Premises . number)
yas'
Z (f ease print)
W (----
Signature Title ri4
(over)
DOH-1555(02/2004)
CONWAY
Owner
.:Fh
C'hnng Conway L1
Address - Plot
633 Bay Rd Queensbury, NY 12804 Seneca
Phone # Lot #
51 8-741 -6793 20H
Deed # Date
4265 5/26/2021
Cost Foundation Y - N
$650.00
Location
North-Nelson
South-Kelly
East-Bates
West-Path
Remarks
I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULATIONS OF THE
PINE VIEW CEMETERY: (� /
SIGNATURE: ! A 0 ,& DATE: Q S ! 6 f _I
SIGNATURE: DATE:
Record of Interments
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CONWAY
NAME James Conway Age: 64
Lot Owner: chong Conway
Lot# Seneca 20h Grave# 1
Case: URN
Died: 4/1 0/2 01 5 Interred: 6/2/21
Funeral Home: Singleton Sullivan Potter
Cemetery: Pine View