Nam, Sang , . /t 3ZL
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
,:: Name First Middle Last Sex
: Sang Chul Nam Male
:;:�, Date of Death Age If Veteran of U.S. Armed Forces,
::- May 19,2014 82 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 —I Accident Homicide I 1 Suicide Undetermined Pending
Circumstances Investigation
im
Medical Certifier Name Title
Christopher D.Hoy
Address
A161 Carey Road, Glens Falls,NY 12801
s:, Death Certificate Filed District Number Register Number_
:: City, Town or Village Glens Falls 5601 3
❑Burial Date Cemetery or Crematory
May 22, 2014 Pine View Crematory
Entombment Address
Ni Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z
I I Removal and/or Held
and/or Address
t_- Hold
co
0 Date Point of
EL N I I Transportation Shipment
Q 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
rr 407 Bay Road, Queensbury,NY 12804
is Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
.::: Permission is hereby g anted to dispose of the huma remains described above as in cate .
:: : Date Issued p Registrar of Vital Statistics _ ez-,P/Y� Gym--c_
r (signature)
K: District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z Z/ /''� /��
tuDate of Disposition 6 -1(t Place of Disposition .'Er L tv.,- 044--
W (address)
CO
CC
(section) (lot num ) (grave number)
Z Name of Sexton or Person ' Charge of Premises 114- , 86111
iy► (please print)
w Signature Title C(2IVO.
f...,
(over)
DOH-1555(02/2004)