Esperti, Andrew H 4 3 3 c
NEW YORK STATE DEPARTMENTOFHEALTH Buriial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Andrew H.Esperti Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/15/2022 74 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 55 Twin Channels Road,Queensbury Town,New York 12804
EManner of Death a Natural Cause Accident 0 Homicide Suicide Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
a Dard Galottl-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Queenslwry District Number Register Number
Cit ,Town or Village 5657 74
Burial Date Cemetery,Crematory or Facility Name
04/19/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
(/)DTransportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
EIReinterment
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
f— Remains are Shipped,If Other than Above
2 Address
Q
W
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/18/2022 Registrar of Vita l Statistics Carats'Iiii4gart4 Barger(Electrom4kg:y Skim°
(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 j/ 117Z Place of Disposition eguV.—, / 0-----
2 /add-ess/
W
th
(r (section) ,Nat number)r. L. Shm tt
(grew number)
Name of Sexton or Person in Charge of Premises �.
Z Z ,/: /,,WW
ease print/ �yrLL
W Signature4 Title �1 �Mi���
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#