Cunningham, John Samuel 4:ill
NEW YORKSTATE DEPARTMENTOFHEALTH � 3bI
Burial - Transit Permit
Bureau of Vital Records
Name First Middle last Sex
John Samuel Cunningham Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/29/2022 74 Years War or Dates 1967-1982
lF Place of Death Hospital,Institution or
Z City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing
Manner of Death 1I Natural Cause ❑Accident 0 Homicide ❑Suicide riUndetermined ❑Pending
0r Circumstances Investigation
W Medical Certifier Name Title
o Shardul Kopper DO
Address
10421 State Route 40,Granville Town,New York 12832
Death Certificate Filed Town Of Granville District Number Register Number
Ci ,Town or Village 5756 27
Burial Date Cemetery,Crematory or Facility Name
05/03J2022 Pine View Crerrratorium
Entombment Address
Cremation Oueensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
of Hold Address
Date Point of
Transportation
Q by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
Re interment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped,If Other than Above
. Address
it
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/03/2022 Registrar of Vital Statistics fenny Limit Alitlastslli('EYictinnicallySr na4
(signature)
District Number 5756 Place Town Of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Ily ,zz Place of Disposition <7n.r V....- L1oc ..
2 (address)
W
to
lr (section) n (lot nu�mb`er/ (gra ee number/
8 Name of Sexton or Person in Charge of Premises G /[)r•
(ple4sse print) /�
W Signature ` "Nr Title GN1L)��
DOH-1555(07/18)p 1 of 2
1„ ! t 11"
Public Health Law Sec. 4145(2b) n,,
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# f