Closson, John NEW YORK STATE DEPARTMENT OF HEALTH^. �' 731 Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Everett Closson Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 25,2014 73 War or Dates
1 Place of Death Hospital, Institution or
EtCity, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined Pending
❑X Natural Cause ❑Accident ❑Homicide n Suicide n n
UM
Circumstances Investigation
Uti Medical Certifier Name Title
a Sean Bain,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register
City, Town or Village Glens Falls,NY 5601 (Y
❑Burial Date Cemetery or Crematory
❑Entombment December 1, 2014 Pine View Crematory
Address
❑X Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
t Hold
N
O Date Point of
NTi Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
# i Permit Issued to Registration Number
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
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described ) ov indicated.
Date Issued /0do2-6/V Registrar of Vital Statistics 4Zr-71-
(signature)
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:
Z
W Date of Disposition I '1'I4 Place of Disposition C:1/4„ Ut j)4.) CrirrorA.--
2 (address)
W
N
W (section) /j' t numbe (grave number)
pName of Sexton or Person in Charge of Premises L k•,r T— tvotAr
Z j; (please pn t)
W Signature L �T�� Title eft M tk t`'i j
(over)
DOH-1555(02/2004)