Dean Jr., Donald L 1(91t
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donald L.Dean Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/27/2021 58 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 30 Rhode Island Avenue,Queensbury Town,New York 12804
W Manner of Death W 1=11=1Undetermined Pending Natural Cause Accident Homicide Suicide
Circumstances Investigation
W Medical Certifier Name Title
G Anne Evans DO
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 225
❑Burial Date Cemetery,Crematory or Facility Name
11/30/2021 Pine View Crematory
ElEntombment Address
EiCremation Queensbury,New York
Donation
Z❑Removal Date Place Removed
and/or and/or Held
H
N Hold Address
0
0• 1-1 Date Point of
U) ❑Transportation Shipment
p by Common
Carrier Destination
❑Disinterment
Date Cemetery Address
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
Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/30/2021 Registrar of Vital Statistics CarolnexRegard Barbirgkctronicalr Signeq9
(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:
Z
111 Date of Disposition l�Z-Z01 I Place of Disposition ) � �e ()ye,L'�,`J CI-'�✓tt��it-
2 (address)
W
N Cr (section) (lot num r) (grave number)
d y
G Name of Sexton or Pers); remises AyhJ�.N
Z (please print)
W Signature Title C9 G`r el_r
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) J 1. 53R 4
Receipt
Human remains of delivered on , 20
Pine'View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#