Center, John NEW YORK STATE DEPARTMENT OF HEALTH �
Vital Records Section T
Burial - 1 r nsit Permit
Name First Middle Last Sex
John _ H. Center Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 25, 2012 65 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 32 Ohio Ave.
13 Manner of Death Natural Cause n Accident Homicide Suicide Undetermined Pending
tii Circumstances Investigation
CI
us Medical Certifier Name Title
0 John Stoutenburg,MD
Address
Glens Falls,NY
Death Certificate Filed I District Number Register Number
City, Town or Village Queensbury,NY 5657 CO
❑Burial 1 Date Cemetery or Crematory
January 30,2012 Pine View Crematory
❑Entombment Address
❑X Cremation Quaker Road, Queensbury, NY 12804
Date ' Place Removed
Z Removal
; and/or Held
and/or
H Hold Address
N
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
I Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I!� Remains are Shipped, If Other than Above
5 Address
CZ
:W
Permission is here y granted to dispose of the human remains describe above as1 indicated.
Date Issued ` 1? c } Registrar of Vital Statistics ___ `-;t , n..�._,,.
(signature)
District Number 5657 Place Queensbury,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 l /3c /i2 Place of Disposition ,.,, Utrr Ct -{ar,,,......
W (address)
CO
rl (section) lot number) (grave number)
QName of Sexton or Person in Charge of remises �A(,)t r Sw-r(f'
`Z (please print)
Signature t� Title C rr dhY}L U(1
(over)
DOH-1555(02/2004)