Russell, Jeffrey M NEW YORK STATE DEPARTMENT OF HEALTH ��
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Jeffrey M.Russell Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/16/2022 75 Years War or Dates
ZZ Place of Death Hospital,Institution or
City,Town or Village Queensbury Town Street Address 15 Laurel Lane,Queensbury Town,New York 12804
`p Manner of Death n Natural Cause nAccident Homicide Suicide rUndetermined ElPending
U f I Circumstances I 'Investigation
LLIQ Medical Certifier Name Title
Donald Merrihew MD
Address
319 Bay Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 120
Burial Date Cemetery,Crematory or Facility Name
08/17/2022 Pine View Crematory
nEntombment Address
Cremation Queensbury,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
CO
0
o- Date Point of
U) Transportation
El- by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
Reinterment 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
a Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/17/2022 Registrar of Vital Statistics Caroline JfiCdegarde Barber(E(ectronicalTySigned)
(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:
I—
Z Date of Disposition $(1f lit Place of Disposition 'gm. Vl,__ .:t.l3
W
2 (a dress)
W
CC U) (section) �� (lot number) SA6‘41'ff
(grave number)
O Name of Sexton or Person in Charge of Premises AN
IL
(plte print)
W Signature , lf--� Title abni1
g /
DOH-1555(07/18)p 1 of 2
I
Public Health Law Sec. 4145(2b)
Receipt
IHuman remains of ic delivered on , 20 i L.
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#