Levine, Howard NEW YORK STATE DEPARTMENT OF HEALTH # it 7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Howard M. Levine Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 23, 2013 79 War or Dates Korean
. Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W" Circumstances Investigation
Ili Medical Certifier Na,Re Title
c x- r" wo , - Cc `( -`
Address
G\-�,s n c-__V\ '- kg,c\
Death Certificate Filed ' Q District Number Register/Number//
City, Town or Village Glens Falls,NY 5601 d
❑Burial Date Cemetery or Crematory
March 25,2013 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
CO
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 Singleton Sullivan Potter 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
▪ Address
Permission is he by ranted to dispose of the human re ins des ibed abov as indica -d.
Date Issued Registrar of Vital Statistics ��i2�_-,--, AIL '
(signs ure)
District Number 56 1 Place Glens Falls,NY
I certify that the remains of the decedent identified above were di posed of inn{��accordance
+with this permit on:
Z V (.►'+^-c f,�w
g
W Date of Disposition 3-aCo'�3 Place of Disposition -l��
(address)
W
co
w (section) (tot number) (grave number)
pName of Sexton or Person in Charge of remises ,�r erwl{
W p/e se print)
Signature7171 Title CY?.,firp1A-to .
(over)
DOH-1555(02/2004)