Sullivan, Dennis Joseph 7010
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dennis Joseph Sullivan Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/05/2022 68 Years War or Dates
F— Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death I I Natural Cause Accident ❑Homicide Suicide Undetermined Pending
W I I
0 Circumstances Investigation
W Medical Certifier Name Title
0 Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 141
Burial Date Cemetery,Crematory or Facility Name
03/07/2022 Pine View Crematory
IllEntombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
F—N Hold Address
0
d Date Point of
(/)❑Transportation Shipment
p by Common
Carrier Destination
II
Date Cemetery Address
Disinterment
Date Cemetery Address
C Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/07/2022 Registrar of Vital Statistics £Megan NoCin(E(ectronica(Cy Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 31113127 Place of Dispositions Cto.......
W (address)
W
CCCC (section) 4,,,, (lot number) (grave number)
0 Name of Sexton or Person in Charge of P mises ��'�
Z `y please print) 7/(
W Signature L/ L Title (�' t"�
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on buria
Official Funeral Directors Reg.or License#