Noone, John NEW YORK STATE DEPARTMENT OF HEALTH
4k � V
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John "Jack" Noone Male
Date of Death Age If Veteran of U.S. Armed Forces,
' January 19, 2012 79 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
GManner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
t Medical Certifier Name Title
0 Dr.Derek Smith,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 1 5601 c
❑Burial Date Cemetery or Crematory
January 23, 2012 Pine View Crematory
Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
I I Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01596
y Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
Ct
W'
0 Permission is her by ranted to dispose of the human(emains scribed a ove as indi ted.
Date Issued Registrar of Vital Statistics C%( „4--' - c,2,'
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above wer dispos2 ed of in accordance with this permit on:
ZPlace of Disposition 't ��1/ C ( Ir.
W Date of Disposition 1/2 H/�Z p d
(address)
W
U)
Ce (section) (lot numq� (grave number)
pp• Name of Sexton or Pers ,, in Charge of emises 4rs� f Q ii
Z (please print)
W Signature Title Ceettil ikiM,
(over)
DOH-1555(02/2004)