Joslyn, William LF�
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
William Scott Joslyn Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/07/2022 85 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 760 Corinth Road,Queensbury Town, New York 12804
UJ
0 Manner of Death 1=1NaturalCause Accident El Homicide Suicide ❑Undetermined Pending
11.1
0 Circumstances Investigation
W Medical Certifier Name Title
CI Aqeel Gillani MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 130
X Burial Date Cemetery,Crematory or Facility Name
IMIIMI 09/10/2022 Pine View Cemetery
Entombment
_ Address
Cremation Queensbury,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
t= Hold Address
N
NTransportation Date Point of
by Common Shipment
Carrier Destination
11
Date Cemetery Address
Disinterment
0 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1. Remains are Shipped,If Other than Above
2 Address
CIC
IL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/08/2022 Registrar of Vital Statistics Caroline xldegarde Barber(ECectronicatTy 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: �p�
Date of Disposition q.il� a a Place of Disposition @ b iN Pb Qt\ 1Et3 1 -- ec
W (address)
Q o (lot number) (grave number)
gName of Sexton or Person in Charge of Premises
Z (please print)
a/ Signature Title �i \'i1"-\en
DOH-1555(07/18)p 1 of 2
1
Public Health Law Sec. 4145(2b) 012942
Receipt
Human remains of ► i, ,,, : 1. . : ' delivered on - - , 20 +, ;
Pine`i Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
JOSLYN
NAME William Scott Joslyn Age: 8 L0
Lot Owner: William & Frederick Joslyn
Lot# Cayuga #1 31 -36 Grave# 32
Case: Concrete
Died: 9.7.22 Interred:91 0.2 2
Funeral Home: Regan Denny Stafford
Cemetery: Pine View