Esmond, John I IS
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
tip; Name First Middle Last Sex
} John F. Esmond Male
r: Date of Death Age If Veteran of U.S. Armed Forces,
j,;, May 11, 2015 89 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
ti Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
,12. Jennifer L.Donovan
;'N$ Address
;:;r,100 Park St,Glens Falls,NY 12801
r Death Certificate Filed District Number Register ymm er
..
City, Town or Village Glens Falls,NY 5601 l�
❑Burial Date Cemetery or Crematory
May 13, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
O Date Point of
D. _ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
r''ti Permit Issued to Registration Number
01 Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
;::.ti 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 desc ibed ab ve , icated.
`;1 Date Issued OS/220/S Registrar of Vital Statistics �.
iti':j / (signature)
rf: District Number 1/456( Place Glens Falls,NY /Z I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition sAlJis Place of Disposition
Z L Cjo.,�
W (address)
Cl)
IY (section) A _ (lot number- (grave number)
Q Name of Sexton or Person in Charge of Premises /Ail —Voir
Z (please print)
W
Signature Title t ti)'+t1 a
(over)
DOH-1555(02/2004)