Barcus, James NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
James Barcus Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/19/2022 78 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death ❑X Natural Cause Accident ❑Homicide ❑Suicide D Undetermined ❑Pending
Circumstances Investigation
W• Medical Certifier Name Title
William Cleaver MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 119
Burial Date Cemetery,Crematory or Facility Name
02/22/2022 Pine View Crematory
❑Entombment Address
gCremation Queensbury Town,New York
❑Donation
ZO ❑Removal Date Place Removed
and/or and/or Held
N Hold Address
O
O. Date Point of
❑
Cl) Transportation
p by Common Shipment
Carrier Destination
El 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
h Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/22/2022 Registrar of Vital Statistics Zoe Morgan(Electronicaf 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:
ZW Date of Disposition 7414 I 2 Z Place of Disposition ,4vk,,,,
(address)
W
� (section) / 1 .DL.(lot
;umber) ��� (grave number)
g Name of Sexton or Person in Charge of PremiZ
pp al—
se print)
W Signature Title
DOH-1555(07/18)p 1 of 2
� 4
1 5810
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#