Glenn, Stephen NEW YORK STATE DEPARTMENT OF HEALTH
#1/1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Stephen D. Glenn Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/19/2018 74 War or Dates Army
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 9 Owen Ave
Manner of Death C Natural Cause D Accident Q Homicide E Suicide 1-1 Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
e Dr Filion,MD
Address
; Glens Falls,NY
Death Certificate Filed District Number Register Number
l City, Town or Village it,2,
Y 9 Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
Entombment November 21, 2018 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
U Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
s
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
E Address
407 Bay Road,Queensbury,NY 12804
v" 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 rem ins scr' ov Ind' ated.
Date Issued ) 1- 2 I- I� Registrar of Vital Statistics `> ;
,-.- (signature)
t ' District Number 5(051 Place //` OtvikCCC c)
t— I certify that the remains of the decedent identified above re disposed of in acc rdanc with this permit on:
w Date of Disposition II 1 L( I)t Place of Disposition 17,,,14,,,. - hr",7toinJ-.,
W (address)
Cl)
cc (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises `try, 6,/ ,SeA A.all
,Z /,� (pease print)
Signature Li 1-1."----
Title C(lkilairDyk
(over)
DOH-1555(02/2004)