Butler, James NEW YORK STATE DEPARTMENT OF HEALTH_
Vital Records Section Burial - Transit Permit
a.a: Name First Middle Last Sex
James Butler Male
a' Date of Death Age If Veteran of U.S. Armed Forces,
October 22, 2012 78 War or Dates
°°' Place of Death Hospital, Institution or
• City, Town or Village Queensbury , Street Address 20 Amethyst Dr.
czt Manner of Death I XI Natural Cause Accident 0 Homicide Suicide Undetermined Pending
tit Circumstances Investigation
us Medical Certifier Name Title
P. William Tedesco MD
Address
3 Irongate Circle,Glens Falls,NY
e.•.' Death Certificate Filed Distr' t Number Register Number
City, Town or Village Queensbury (9 S n )3
Lf
❑Burial Date Cemetery or Crematory
October 25, 2012 Pine View Cremation
II Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
O Removal and/or Held
and/or Address
H Hold
N
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Date I Cemetery Address
Disinterment 1
Reinterment Date Cemetery Address
Permit Issued to Registration Number
a, 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
Ce
tkt
k.' Permission is hereby g anted to dispose of the human re ins describedfibove as indicated.
L,4 Date Issued I , Registrar of Vital Statistics � /
c, l (. ./LC—.�
(signature)
District Numbers(,( ") Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition IU-Z&,-it. Place of Disposition ai f��mtot,r
2 (address)
W
CO
OC (section) - (lot number) r (grave number)
pName of Sexton or Person in Charge f Premises P,Sfi - el.,t
Z (please print)
W SignatureAL
Title ( h1 ftrd4,
(over)
DOH-1555(02/2004)