South, John M. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John M.South Male
Date of Death Age If Veteran of US.Armed Forces,
02/20/2021 48 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Warrensburg Town Street Address 25 Sandford Street,Warrensburg Town, New York 12885
p Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
GMedical Certifier Name Title
Michael Bell MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Warrensburg 5660 7
❑Burial Date Cemetery,Crematory or Facility Name
02/24/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
O ❑Removal Date Place Removed
p and/or and/or Held
N Hold Address
lA. Date Point of
N ❑Transportation
a by Common Shipment
Carrier Destination
Date Cemetery Address
❑Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
a Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/23/2021 Registrar of Vital Statistics Pamela M Lloyd(Elactronicat[y Signed)
(signature)
District Number 5660 Place Warrensburg, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 7 29-24Zi Place of Disposition Ply)a J��,)UJ
JQ y� �►
2 (address)
W
N (section) /,(lot number) (grave number)
O Name of Sexton or Person in rge Premises
Z (please print)
W Signature Title L ie yvt ,/
DOH-1555(07/18)pi of 2
y F
Public Health Law Sec. 4145(2b) 0145 F6
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#