Dodge, Edward I W 71 e
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section "` Burial - Transit Permit
Name First Middle Last Sex
r , Edward John Dodge Male
ffr; Date of Death Age If Veteran of U.S. Armed Forces,
ff September 27, 2015 80 War or Dates Vietnam
�• 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 Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Sean Bain
Address
rf▪ 100 Park St,Glens Falls,NY 12801j
Death Certificate Filed District Number Register In /` ?
City, Town or Village 56
❑Burial Date Cemetery or Crematory
September 28, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
NTransportation Shipment
p' by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
{f Permit Issued to Registration Number
;.••X�, 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
Permission is hereby granted to dispose of the human remains described above as indicated.
I .
1
Date Issued �3 12g/20 3 Registrar of Vital Statistics I/�CM,�y-Q,. �Jl' fti--C6l
(signature)
▪ District Number 5601 Place 6 _cuv\,S To, \\� �D
fir. ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 9-3d-)S Place of Disposition P;nP tire.,),,) Cr2 n i- '-i twl
2 (address)
W
N
O (section) / (lot number) (grave number)
QName of Sexton o Per n in Charge of Premises -Nu-, a./ L��,vH Z.cji.-4-
'Z (please print)
Signature Title r^e.,77w1-0 a S1 14.
(over)
DOH-1555(02/2004)