Beaver, Anthony Earl ZICI
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Anthony Earl Beaver Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/04/2022 83 Years War or Dates 1956-1961
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
UJ
p Manner of Death ❑X Natural Cause Accident 0 Homicide DSuicide FlUndetermined 17 Pending
111
Circumstances Investigation
0W Medical Certifier Name Title
P John Quaresima MD
Address
9 Carey Road,"Queensbury Town,New York 12804
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 148
BuriM Date Cemetery,Crematory or Facility Name
03/08/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
4s E Removal Date Place Removed
- and/or and/or Held
(—- Hold Address
CO
0
O. Date Point of
to Transportation Shipment
Q by Common
Carrier Destination
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
i.J° Remains are Shipped,If Other than Above
a Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/08/2022 Registrar of Vital Statistics Megan Nolin(ECectronicai.TySigned)
(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-
W _3 Date of Disposition I IO I Z2 Place of Disposition 47Ki. . srw_.__
ki
2 (address)
IJJ
NCC (section) (lot number) e., (grave number)
GName of Sexton or Person in Charge of Premises �'� `'—
ll
� (p!e se print)
W Signature 2 Title � � �
DOH-1555(07/18)p 1 of 2
TO • y , E 7
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#