Barrett, Jr. William NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
`' ' Name First Middle Last Sex
William E. Barrett,Jr. Male
r<>'f Date of Death Age If Veteran of U.S. Armed Forces,
::g May 24, 2012 73 War or Dates
', Place of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Death IX Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
William Borgus Dr.
Address
14 Manor Drive,Queensbury,NY 12804
j Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 2`3
❑Burial Date Cemetery or Crematory
❑Entomb men May 29,2012 Pine View Crematorium
t
Address
®Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ• ❑Removal and/or Held
and/or Address
E Hold
N
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
, Permit Issued to Registration Number
':<=? Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
r 407 Bay Road,Queensbury,NY 12804
M 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 it dicated.
Date Issued .S/2S/!Z Registrar of Vital Statistics wC/V-\5Z
„ (signature)
District Number 5601 Place Glens Falls,NY
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition GI I lit Place of Disposition e..,,A)t 6 daiuN.
2 (address)
W
N
cc (section) (lot number' (grave number)
pName of Sexton or Person in Charg of Premises I hci -'aur+it
Z (please print)
W u_ tfr o
Signature 4,,L_ Title CV
(over)
DOH-1555(02/2004)