Juckett, Stanely 0 ` 1
NEW YORK STATE DEPARTMENT OF HEALTH it $ 2�,�
Vital Records Section tr .. Burial - Transit Permit
f r Name First Middle Last Sex
`" Stanley Juckett Male
:'':;''4, Date of Death Age If Veteran of U.S. Armed Forces,
September 20,2014 87 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
•- Manner of Death 0 Natural Cause El Accident E Homicide 0 Suicide FTUndetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
c Michael Lieberth MD
Address
17 Baywood Drive,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
F` City, Town or Village Glens Falls,NY 5601 t_ (4 CD
❑Burial Date Cemetery or Crematory
September 23, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
i Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
r' Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
-" 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1;� Remains are Shipped, If Other than Above
Address
,, Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9/2 7_fl ty Registrar of Vital Statistics LA)c k.;J
;; (signatur
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition gjl3)8 Place of Disposition u� Ciwrct....
2 (address)
W
N
re (section) . t num/W) (grave number)
pName of Sexton or Person in Charge of Premises GIRato�r SraNa
Z ,/ (please print)
Signature G i,yi Title elLeMA
I (over)
DOH-1555(02/2004)