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Belle,Anthony Andrew LF NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Anthony Andrew Belle Male Date of Death Age If Veteran of U.S.Armed Forces, 12/12/2020 82 Years War or Dates Nat.Guard 1— Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ❑X Natural Cause El Accident Homicide ❑Suicide El Undetermined Pending V Circumstances Investigation W Medical Certifier Name Title a Aaron Heckler PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 570 ©Burial Date Cemetery,Crematory or Facility Name 12/16/2020 Pine View Cemetery ❑Entombment Address ▪Cremation Queensbury Town,New York Donation Removal Date Place Removed and/or and/or Held F—N Hold Address 0 a Date Point of W ❑Transportation p by Common Shipment Carrier Destination IDDisinterment Date Cemetery Address Reinterment 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 t— Remains are Shipped,If Other than Above a Address W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/14/2020 Registrar of Vital Statistics p6erMnrlretv Cultic(E/ctronicad Sfgtted) (signature) District Number 5601 Place Glens Falls, 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 1 2/1 6/2 0 2 Glace of Disposition 21 Quaker RD. Queensbury, NY 1 2804 2 (address) W Erie-68—C (section) (lot number) (grave number) SName of Sexton or Person in Charge of Premises Connie Goedert Z (please print) W Signature Title Superintendent DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 012830 Receipt Human remains of delivered on , 20 , Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# BELLE NAME Anthony Andrew Belle Age: 82 \ r Lot Owner: Anthony Belle Lot# Erie 68-C Grave# 1 Case: Concrete Died: 1 2/1 2/2 0 2 0 Interred: 12/16/2020 Funeral Home: Singleton Sullivan Potter FH Cemetery: Pine View