Dashnaw, Cody Thomas NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Cody Thomas Dashnaw Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/09/2021 29 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Hudson Falls Village Street Address 13 Poplar Street, Hudson Falls Village,New York 12839
111
W Manner of Death ❑ Natural Cause I:Accident ElHomicide ElSuicide ❑Undetermined ❑X Pending
V Circumstances Investigation
W Medical Certifier Name Title
G John Aiken Coroner
Address
40 Burquist Road,Fort Ann Town,New York 12827
Death Certificate Filed District Number Register Number
City,Town or Village Hudson Falls Village 5726 21
❑Burial Date Cemetery,Crematory or Facility Name
08/13/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
▪Donation
Removal Date Place Removed
and/or and/or Held
F—N Hold Address
0
O. Date Point of
N ❑Transportation
p 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
}- Remains are Shipped,If Other than Above
Address
LC
111
Cl. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/11/2021 Registrar of Vital Statistics Cyntlrra.7Bardin(EYectronacaf 5gnei9
(signature)
District Number 5726 Place Hudson Falls Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
Z Date of Disposition /yQ6( Place of Disposition Pik o� e„) ('re-02 t-
W
2 (address/
W
CC (section) (lot number] (grape number)
8 Name of Sexton or Person in Charge f Premises , x nie) • ti4z)`'
z l(please print)
W Signature ` Title 0�Q�T4
DOH-1555(07/i8)p t of 2
I 5 n
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#