Bemis, Daniel lf
NEW YORK STATE DEPARTMENT OF HEALTH' ' ' 531
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Daniel H. Bemis Male
•::::' Date of Death Age If Veteran of U.S. Armed Forces,
October 9,2012 50 War or Dates
• Place of Death Hospital, Institution or
• City, Town or Village Queensbury Street Address 38 Berry Patch Dr.
ri Manner of Death Natural Cause n Accident n Homicide Suicide n Undetermined Pending
W. Circumstances Investigation
Medical Certifier Name Title
I° Timothy Murphy
Address
52 Haviland Ave.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
• City, Town or Village Queensbury,NY 5657 1oC
❑Burial Date Cemetery or Crematory
❑Entombment October 12,2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
co
0 Date Point of
y n Transportation Shipment
'p by Common Destination
_ Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury,NY 12804
;:._1 Name of Funeral Firm Making Disposition or to Whom
ib:+, Remains are Shipped, If Other than Above
E Address
g
1 1 Permission is hereby granted to dispose of the human remains described� aboY a as indicated.
• Date Issued IDI I a-)cb�, Registrar of Vital Statistics Gr . -� `�1•• 06(L��
(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:
ui Date of Disposition to I is lit Place of Disposition Ow-,llu
CrtnY,�-pr sue,
(address)
W
Cl)
CC (section) li, (lot number) r (grave number)
p �y2L Name of Sexton or Person in Charge f Premises po,� c u
Z (pljase print)
W
Signature Title C'L€.nri 0e
(over)
DOH-1555(02/2004)