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Sweeney, Adam Nicholas j Clik NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Adam Nicholas Sweeney Male Date of Death Age If Veteran of U.S.Armed Forces, 12/15/2021 18 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ©Natural Cause ❑Accident ❑Homicide El Suicide El Undetermined ❑Pending W Circumstances Investigation 8 Medical Certifier Name Title 0 Sean Bain MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 606 Burial Date Cemetery,Crematory or Facility Name 12/21/2021 Pine View Crematory Entombment Address KuCremation Queensbury,New York Donation Z Removal Date Place Removed and/or and/or Held aHold Address O Q. Date Point of fa ❑Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Or Name of Funeral HomeReganDenny Denn 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 Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/17/2021 Registrar of Vital Statistics cR96ertAndrew Curtis(ECectronicalfy Signed) (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: ii Date of Disposition Mittill Place of Disposition IL n V,,,,_ ( �rj'd 2 (a dress) W CC (section) (l number) (grave number) a Name of Sexton or Person in Charge of P mises r,, �, SNMti please p tl Z W Signature Title rs�"LTD( DOH-1555 l07/18►p 1 of 2 ,ter ) 1 5466 Public Health Law Sec. 4145(2b) A Receipt P Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#