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Russell Sr., Louis James NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records LI(. 117,F)\... Burial - Transit Permit Name First Middle Last Sex Louis James Russell Sr Male Date of Death Age If Veteran of U.S.Armed Forces, 12/25/2020 81 Years War or Dates Navy I._ Place of Death Hospital,Institution or WCity,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death a Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W U Circumstances Investigation aLIJI Medical Certifier Name Title Shahid Ahmed MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 599 ©Burial Date Cemetery,Crematory or Facility Name 01/06/2021 Pine View Cemetery 0 Entombment Address ❑Cremation Queensbury,New York ❑Donation Removal Date Place Removed and/or and/or Held ~ Hold Address CO 0 O. Date Point of (/) 0 Transportation G by Common Shipment Carrier Destination Disinterment 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 H Remains are Shipped,If Other than Above Address IX W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/29/2020 Registrar of Vital Statistics Rp6ertAndrew Curtzr(Ef ctronicall:y Signed) (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- Date of Disposition 1 6 2 0 21 Place of Disposition Quaker Rd 2 8 0 4 W / / 21 Oueensbur NY 1 2 (address W Erie 43 C 1 N Et (section) (lot number) (grave number) GName of Sexton or Person in Charge of Premises Connie GOedert W (please print) Signature dOn/U; d1- 6'0-'9--d--CAC Title Superintendent DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 012836 Receipt Human remans of - l: ,: delivered on , 20 , , , i r'�', J ; Is Pine View Cenetery Representing the funeral home named'�on burlap permit Official Funeral Directors Reg.or License# RUSSELL SR. NAME Louis James Russell Sr. `age: 81 Lot Owner: Colleen Russell Lot# Erie 43 C Grave# 1 Case: Concrete Died: 1 2/2 5/2 0 2 0 Interred: 1 /6/2 0 21 Funeral Home:Singleton Sullivan Potter FH Cemetery: Pine View