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Sullivan, Edward NEW YORK STATE DEPARTMENT OF HEALTH r q Vital Records Section Burial - Transit ermit Name First Middle Last Sex Edward S. Sullivan Male Date of Death Age If Veteran of U.S. Armed Forces, February 15, 2013 87 War or Dates World War II Place of Death Hospital, Institution or Z City, Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death n Natural Cause n Accident ❑Homicide ❑Suicide Undetermined Pending W Circumstances Investigation w Medical Certifier Name Title O Christopher Hoy,MD Address 102 Park Street,Glens Falls,New York 12801 Death Certificate Filed District Number RegisterN�nber City, Town or Village Glens Falls 5601 (� ❑Burial Date Cemetery or Crematory February 21, 2013 Pine View Crematorium ❑Entombment Address ©Cremation 21 Quaker Road, Queensbury,NY 12804 Date Place Removed ZO n Removal and/or Held and/or Address H Hold U) O Date Point of N ❑Transportation Shipment p by Common Destination Carrier — Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan & Denny Stafford Funeral Home 01443 Address 53 Quaker 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 above as indicated. Date Issued 2 f i c') / /3 Registrar of Vital Statistics w C w-A-A- (signature) District Number 5601 Place Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition Place of Disposition W (address) Cl) CL (section) (lot number) (grave number) QName of Sexton or Person in Charge of Premises Z (please print) W Signature Title (over) DOH-1555(02/2004)