Logan Jr, John 4- 1-(.7
NEW YORK STATE DEPARTMENT OF HEALTH `Vital Records Section Burial - Transit Permit
;: , Name First Middle Last Sex
John G. Logan,Jr. Male
{tip Date of Death Age If Veteran of U.S. Armed Forces,
;r October 22, 2014 47 War or Dates
v*` Place of Death Hospital, Institution or
—City, Town or Village Queensbury Street Address 25 McEchron Lane
10 Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Gerald F Abess
r r Address
{* 3 Irongate Center, Glens Falls,NY 12801
{/ Death Certificate Filed District Numbe5657 Register Number
City, Town or Village Town of Queensbury r L{
❑Burial Date Cemetery or Crematory !
October 27, 2014 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
N
0 Date Point of
uTransportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
1 Reinterment
Date Cemetery Address
::j: Permit Issued to Registration Number
r Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
; Address
'r. 407 Bay Road, Queensbury, NY 12804
rr,:;. Name of Funeral Firm Making Disposition or to Whom
k:'; Remains are Shipped, If Other than Above
Address
.:
Permission is hereby granted to dispose of the human remains described above as indicated.
,r
:r. Date Issued J C')l�-L ID 4egistrar of Vital Statistics � , C)PJ1.1�N
f (signature)
i:ir : District Number 5657 Place Town of Queensbury
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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to Date of Disposition ID(/city Place of Disposition FAL C,. ,,.4..
2 (address)
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CO
0 (section) //�j (lot numb) (grave number)
QName of Sexton or Person in Charge of Premises t= �, ^ 040
Z Pease print)
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Signature Title CfeEiti 111W
(over)
DOH-1555(02/2004)