Emerson, James W NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
.....:.:.James.:.tnT.:...IIzrson...............: Male......::.::::.
Date of Death Age If Veteran of U.S.Armed Forces,
Ma .ch....1.7::..1.991..: War o..Dates
1-� ...:..::..... p
� Place o Death Hospital, Institution or
'U"1 City,Town or Village City of Glens Falls Street Address Glens Falls Hospital
W Manner of Death Natural Cause ❑Accident ❑ Homicide ❑ Suicide ❑ Undetermined � Pending
Circumstances Investigation
.........:::... ... -..... ... .... ....... . ...:::::: ......... .......::....:.. .......
al Medical Certifier Name Title
..-Jos -h...Mihi ..:..:.....MD.........: .. ....... ......... .....: ::_..
0 -:....:..: ......::.:... .,. .:..:...
ress
pp. ... St. ... .....ns...Falls-,New:.:York.. _....... ...........- ... .. ............ : __..... ...:::......
DeatTi` eWificate I-iledP District Number Register Number
City,Town or Village City of Glens Falls 5601
Date Cemetery or Crematory
Burial
March 19, 1991 Pine View Crematory
. .... ........ .::..:. ...._....
❑Cremation Address
.:.........Tn.-..of....Queensbury,::.New...York. ......... ............ ........ .....
Z Date Place Removed
0 ❑ Removal and/or Held
F- and/or Hold ...:. ..... . ......... ......... ........... ... .......
Address
a Date Point of _ :::::...:: _.:.. .:::::::....
N []Transportation by Shipment
p Common Carrier ........ .. ............. ..::::......: . :.::........................ ..:.
Destination
.... ................ ..... .. ..: ... :::: _. . -.........
❑ Disinterment Date Cemetery Address
.............
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Sullivan Minahan and Potter Funeral Home 01933
...... .:..... ......::: ..... : :: ........--:... ......... ...
Address
67 Park St. Glens Falls, New York,.,12801 _
...... ,.. .. . ....
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
.............................................. ........ ..... . .................._ .::: ::.......
ut>
Address
i '
... ...... ....................: ... ..... ... _�re
Permission is hereby granted to dispose of the humins scribe ;above as indicated.
Date Issued — — Registrar of Vital Statistics
signature) G
District Number Z Place
I certify that the remains of the decedent identified above were dispos in accordance with this permit on:
® f
Z; Date of Disposition o2D'-/ Place of Disposition /,(/
�;' (address)
w'
C n (section) r� (lot number) (grave number)
p' Name of Sexton or erson in Charge of Premises
Z g lease print) —�Ti�T�y ?'
W' Si nature Title fCC. i
DOH-1555 (10/89) p. 1 of 2 VS-61