Healy, James Joseph NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
James Joseph Healy Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/05/2021 73 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing
p Manner of Death ❑X Natural Cause 0 Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
IU• Medical Certifier Name Title
O Michael Miles MD
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 6
Burial Date Cemetery,Crematory or Facility Name
01/07/2021 Pine View Crematory
EiEntombment Address
0 Cremation Queensbury,New York
Donation
OZ ❑Removal Date Place Removed
and/or and/or Held
~N Hold Address
0
L1. 1-1 Date Point of
Cl) ❑Transportation Shipment
p by Common
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
1. Remains are Shipped,If Other than Above
2 Address
tr
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/07/2021 Registrar of Vital Statistics Carolnexldegar/Bar6er(!YectronicallySignea9
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W
/Date of Disposition 9- L/ Place of Disposition „1e tf�?u�
2 (address)
W
CC
N (section) (lot number) (grave number)
O Name of Sexton or Person in Char e of Prem. es Aye
(please print)
Z � `�
IU Signature Title C��er� !—
DOH-1555(o7/18)p i of 2
Public Health Law Sec. 4145(2b) 314 395
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#