Milen, Alfred Adolph . .a 2III
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Alfred Adolph Aden Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/16/2022 82 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
E Mannerof Death ❑
ID Natural Cause Accident El HomicideSuicide Undetermined riPending
VCircumstances Investigation
ILI G Medical Certifier Name Title
Jennifer Donovan DO
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed Town of Queensbury District Number Register Number
Cit ,Town or Village
g 5657 54
Burial Date Cemetery,Crematory or Facility Name
03/17/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0 DRemoval Date Place Removed
F and/or and/or Held
(7) Hold Address
0
d Date Point of
CO Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
DReinterment
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 Otherthan Above
2 Address
uE
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/17/2022 Registrar of Vital Statistics Cary!ins.2Cr!dgardfsBas r('E etmnicaKySignsd)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
•
WDate of Disposition 3 jig lit Place of Disposition 'b e At.A— _
a (address)
W
CO
Q (section) 1 (lot n
uumber) (gra re number)
SName of Sexton or Person in Charg f Premises r41�1>. 44
Z (Oise print/ /I,,,�,.
W Signature -� Title L 1v�I"�We
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 burial permit
Official Funeral Directors Reg.or License# •