Ives, Stephen NEW YORK STATE DEPARTMENT OF HEALTH' ) ° V
Vital Records Section Burial - Transit Permit
rA Name First Middle Last Sex
'f Stephen Ives Male
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Date of Death Age If Veteran of U.S. Armed Forces,
September 27,2013 62 War or Dates
,,;f Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death [ I Natural Cause n Accident _Homicide n Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Eric Pillemer MD
Address,
14
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%,+�y Death Certificate Filed District Number Register N mber
City, Town or Village Glens Falls 5601 o
❑Burial Date Cemetery or Crematory
September 30, 2013 Pine View Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
z C Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
D Reinterment Date Cemetery Address
,f, Permit Issued to Registration Number
f
r
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
„! Address
407 Bay Road,Queensbury,NY 12804
'f Name of Funeral Firm Making Disposition or to Whom
i` .f Remains are Shipped, If Other than Above
Address
{r0, Permission is hereby granted to dispose of the human remains described above as indicated.
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Date Issued 9 / 30113 Registrar of Vital Statistics (.N
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fr (signature)
0. District Number 5601 Place Glens Falls
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition log7,1j3 Place of Disposition ,, we r0'`-
(address)
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W (section) 1 (lot number (grave number)
pName of Sexton or Pers in Charge of Premises G Zn i t,Kii
Z / lease print)
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Signature .r k��1*—�
/ (over)
DOH-1555(02/2004)