Serra Jr., Joseph r c�
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Joseph Serra Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/04/2021 95 Years War or Dates 1944-1946
1.. Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death ❑X Natural Cause Accident ❑Homicide p Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
WGt Medical Certifier Name Title
Marvin Davidowitz MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 380
❑Burial Date Cemetery,Crematory or Facility Name
09/07/2021 Pine View Crematory
ElEntombment Address
X❑Cremation Queensbury Town,New York
❑Donation
Z Removal Date Place Removed
and/or and/or Held
1— Hold Address
N
0
LL Date Point of
0 ❑Transportation Shipment
3 by Common
Carrier Destination
Date Cemetery Address
11 Disinterment
Date Cemetery Address
Reinterment
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
i.• Remains are Shipped,If Other than Above
IAddress
W
a.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/07/2021 Registrar of Vital Statistics Ro6ert,/?ndrewCurzz'tglectronicaf SWne4
(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:
H ((L 40---
Date of Disposition 4 1'�(� Place of Disposition Mc l
Ili
II address/
W
W (section) n(lot number) (grave number)
gName of Sexton or Person in Charge of Pre ' es A(!� L "4LT
z
(pte e print) /�,
W L� Title t ►"�"''�" / f/
Signature
DOH-1555(07/18)p 1 of 2
0 _ 511.
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
in Pe View Cemetery Representing the funeral home named on burial permit
'Official Funeral Directors Reg.or License#