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Carey, William J NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex William J Carey Male Date of Death Age If Veteran of U.S.Armed Forces, 11/29/2021 92 Years War or Dates 1.. Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 71 Longview Drive,Queensbury Town,New York 12804 p Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide 0 Undetermined ❑Pending W C.) Circumstances Investigation WC Medical Certifier Name Title Mary Stein NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 228 Burial Date Cemetery,Crematory or Facility Name 11/30/2021 Pine View Crematory 0 Entombment Address ElCremation Queensbury Town,New York ❑Donation ❑Removal Date Place Removed — and/or and/or Held N Hold Address 0 d. Date Point of to Transportation b by Common Shipment Carrier Destination Disinterment Date Cemetery Address ElReinterment 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 I— Remains are Shipped,If Other than Above 2 Address IL W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/30/2021 Registrar of Vital Statistics Caroline 2{i(degarde Barber(E(ectronicalTy Signed) (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: Date of Disposition IZ f Place of Disposition gcCL 6f,,__. UJ a (address) W OC N (section) // (lot number) (grave number) gName of Sexton or Person in Charge of Premises f i uti z (pleat¢print) W Signature Title l'iMW DOH-1555(07/18)p 1 of 2 i 1 •__ 0 5399 Public Health Law Sec. 4145(2b) Receipt 1 Human remains of \ delivered on , 20 I Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#