Bradley, James Harold II$10
NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
James Harold Bradley Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/04/2020 82 Years War or Dates Marines
F- Place of Death Hospital,Institution or
Z City,Town or Village Lake Luzerne Town Street Address 16 Tall Pines Drive,Lake Luzeme Town,New York 12846
WI
W Manner of Death ❑X Natural Cause 0 Accident 0 Homicide ❑Suicide ❑Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
Heather Johnson NP
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Lake Luzeme 5656 18
❑Burial Date Cemetery,Crematory or Facility Name
11/09/2020 Pine View Crematory
Ei Entombment Address
X❑Cremation Queensbury,New York
a❑Donation
Date Place Removed
Z ❑Removal
and/or and/or Held
— Hold Address
N
co ❑Transportation Date Point of
a by Common Shipment
Carrier Destination
EIDisinterment Date Cemetery Address
EiReinterment 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
Remains are Shipped,If Other than Above
Address
ir
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/09/2020 Registrar of Vital Statistics CyntlrraSlrertvoarllEkctrvnicall:y Swne9
(signature)
District Number 5656 Place Lake Luzeme, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E
Date of Disposition II !q 1 to Place of Disposition A:Tit G.�L
(address)
11.1
i/1
Ce (section) ff apt number/ (grave number)1Name of Sexton or Person in Charge of P emisesZ______ �.. t. ,p�nLi
1 (phase print)
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0 1 4 1 78
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#