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Martin, Earl Thomas 11II5g NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Earl Thomas Martin Male Date of Death Age If Veteran of U.S.Armed Forces, 10/24/2020 55 Years War or Dates ZZPlace of Death Hospital,Institution or City,Town or Village Albany Street Address St Peters Hospital 111 p Manner of Death © Natural Cause El Accident ID Homicide ❑Suicide ❑Undetermined 0 Pending LU 0 Circumstances Investigation CMedical Certifier Name Title Erin Clausi NP Address 315 S Manning Blvd,Albany,New York 12208 Death Certificate Filed District Number Register Number City,Town or Village Albany 0101 2296 ❑Burial Date Cemetery,Crematory or Facility Name 10/26/2020 Pine View Crematory 0 Entombment Address X❑Cremation Queensbury Town,New York ElDonation 0 ❑Removal Date Place Removed and/or and/or Held F Hold Address N 0 A. ❑Transportation Date Point of 5 by Common Shipment Carrier Destination Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom F- Remains are Shipped,If Other than Above a Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/26/2020 Registrar of Vital Statistics Danielle S GiCTespie(Electronically Signed) (signature) District Number 0101 Place Albany, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— W Date of Disposition /0 all I ID Place of Disposition .7(1 Imo.._, 2 (address) W CO CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises 4 1,,}�1� v�-►omit z ���� /p ase print/ UJ Signature Title 0.0"+T-41. DOH-1555{07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 01414 Receipt Human remains of delivered on Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#