Linehan, Jeremiah NEW YORK STATE DEPARTMENT OF HEALTH t 1.' t j 1 L
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jeremiah Francis Linehan Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 16, 2014 76 War or Dates n/a
t,;, Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 44 Willowbrook Road Apt 112
Manner of Death �t �1 Undetermined Pending
Natural Cause �Accident I I Homicide l i Suicide [�
Circumstances Investigation
Medical Certifier Name Title
" Dr Robert Sponzo,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Repir Number
City, Town or Village Town of Queensbury 5657
❑Burial Date Cemetery or Crematory
November 18,2014 Pine View Crematorium
❑Entombment Address
ID Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z —Removal and/or Held
0 —and/or Address
F' Hold
u)
0 Date Point of
N El Transportation Shipment
p 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
a 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
X Address
1
¢" Permission is hereby granted to dispose of the human re s des ibed a ovv as indicated.
1 Date Issued l 1 j') c Registrar of Vital Statistics e�e •�V AA.
(signature)
District Number 5657 Place Town of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition il/i /I'/ Place of Disposition 'th... (t-'--i'---
2 (address)
W
0
re (section) / (lot number— (grave number)
QName of Sexton or Person in Charge of Premises G' r.a L �020
Z f please print)
w i Title (1/40^ '�'��
Signature
(over)
DOH-1555(02/2004)