Crosse, John NEW YORK STATE DEPARTMI=NT OF WEALTH
Vital Record, Sectirm Burial - Transit Permit
Nance First kliddle Last Sex
John W. Crosse _ Male
Date of Death Aye If Veteran of U.S. Armed Forces,
1/25/98 _ I 63 War or Dates No
Place of Death Hospital, hislilutiorr or
City, Town_or Village Queensbury _ Street Address_17 Brick Oven Rd.
Manner of Dealt Natur at Cause Accident Homicide R1 Suicide Undetermined Pending
Circumstances Investigation
Medical Certilier Name Title
_ William F. Orluk Coroner
Addi ess
Box 673 Chestertown NY 12817
Death Cer(ilicale Filed District Number Register Number
City, Town or Village Queensbury 5657
Date Cemetery or Crematory
❑Burial 1/30/98 Pine View Crematorium
Address
®Cremation Queenshury,NY
— -Date—— — - -- - --T—pl ice Removed
0 Removal —__ _I and/or Held
ancijoi Address
Hold
Q Date Point of
Q-Transportation _ Shiprnerrt
0 by Common Destination
Disirtlermetrt Date— -- ---- — Cemetery Address
[]Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Sullivan — Minahan & Potter 01837
Address --- —
407 Bay Rd. Queensbury,NY
Natne of Funeral Firtn Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r ns deas indic ted.
Date Issued 1 ��a�aR Registrar of Vital Statistics (>-� cr�be-�
�
si r► ' re)
District Number 5657 Place Queensbury
I certify that the ►emains of the cf cedenl identified above were disposed of in accordance wilt this permit on:
F.7
Z Date of Disposition � o7` Place of Disposition �j/S/ f /�itJ C
* (address)
t
cn
LE (section) �D (lob riumberL (grave number)
Name or Serlo or Person in Change of Premises
W (please le Tr' S
Signature Title �
DOW1555 (10/89) p. 1 of 2 VS-61