Troelstra, Harry NEW YORKSTATE DEPARTMENT OF HEALTH C
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Harry Troelstra Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/28/2022 89 Years War or Dates
f.., Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 103 Burnt Hills Drive,Queensbury Town,New York 12804
pManner of Death II Natural Cause Accident 0 Homicide Suicide Undetermined ❑Pending
W Circumstances Investigation
V Title
W Medical Certifier Name
0 Sean Campanie NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 82
X Burial Date Cemetery,Crematory or Facility Name
05/03/2022 Pine View Cemetery
Entombment
_ Address
Cremation Queensbury Town,New York
Donation
ZO 0 Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
a. Date Point of
(/) Transportation Shipment
G by Common
Carrier Destination
Date Cemetery Address
Disinterment
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
1— Remains are Shipped,If Other than Above
a Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/29/2022 Registrar of Vital Statistics Caroline gfildigarde Barber(ECectronicalTy Signed)
(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:
IF— / 1679)71
Z Date of Disposition 5 Place of Disposition , i �j,r ik/2 /'�n 6t, rshif y 1V 2
(address)
(W/)EC (s ) of number) (grave number)
0 Name of Sexton or Person in Charge] Premises �'' --,`�1. "`^"`
(please print)
1!J Signature / Title Su'. cRA
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
012909
Receipt
1 Human remains of delivered on_ , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
TROELSTRA
NAME Harry Troelstra �� Age: 89
Lot Owner: Harry & Irene Troelstra
Lot#Erie 6 3 D Grave# 1
Case: Concrete
Died: 4.2 8.2 2 Interred: 5.3.2 2
Funeral Home: Singleton Sullivan Potter
Cemetery: Pine View
TROELSTRA
Owner
Harry & Irene Troelstra
Address Plot
103 Burnt Hills Dr. Oueensbury, NY 12804 Erie
Phone # Lot #
518-793-9288 634
Deed # Date
4203 8/7/2020
Cost Foundation Y - N
$650.00 )( Q : 6 1306
Location West-Vacant
East-Ward
South-Tinisinger
North-Vacant
Remarks
I ACKNOWLEDGE THE RECEI'i OF THE RULES AND REGULATIONS OF THE
PINE VIEW CEMETERY;`
SIGNATUR: l t ) 1 G)/C� DATE: O 94 J/(Zv
SIGNATURE: � �,�j i1 c�� Cs � DATE:() %G/7/&o
Record of Interments
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