Magno, John NEW YORK STATE DEPARTMENT OF HEALTH ' �' �l"
Vital Records Section Burial - Transit Permit
;c Name First Middle Last Sex
John Alex Magno Male
• Date of Death Age If Veteran of U.S. Armed Forces,
May 19,2014 71 War or Dates
}: Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address 216 Konci Terrace
g Manner of Death X Natural Cause Accident 1 !Homicide Suicide Undetermined Pending
Ili Circumstances Investigation
w Medical Certifier Name Title
: Ageel A. Gilanni,MD.
Address
• 102 Park St. Glens Falls,NY
Death Certificate Filed District Number Register Number
:`:• City, Town or Village Lake George
❑Burial Date Cemetery or Crematory
El Entombment May 21, 2014 Pine View Crematorium
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
NTransportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
s: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury,NY 12804
iiiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
E Address
It
ILI
• :: Permission is hereby granted to dispose of the human remains de cribed abo e as indicated.
• Date Issued ',57 ///t/ Registrar of Vital Statistics ( j /
(signet e)
District Number 57c7 Place Lake George
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z n �
W Date of Disposition 'P( Place of Disposition 'l?r elovl/
gt`,
2 (address)
W
co
0 0 (section) (lot numbe(� (grave number)
p Name of Sexton or Person .n Charge of Premises ti �fediiin"
Z lease print)
Signature Title CrleAMtit
(over)
DOH-1555(02/2004)