Carney, John J Sr. '' (------C.5- # 4 3E)
NEW YORK STATE DEPARTMENT OF HEALTH / Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John J Carney Sr Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/06/2022 77 Years War or Dates 1963-68
l_ Place of Death Hospital,Institution or
Z City,Town or Village Corinth Town Street Address 10 Brookview Drive,Corinth Town,New York 12822
111
O Manner of Death El Natural Cause Accident 0 Homicide []Suicide Undetermined Pending
111
0 Circumstances Investigation
WMedical Certifier Name Title
O George Siniapkin MD
Address
604 Palmer Avenue,Corinth Town,New York 12822
Death Certificate Filed Town Of Corinth District Number Register Number
City,Town or Village 4553 13
idBurial Date Cemetery,Crematory or Facility Name
08/08/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
CO
0
a. Date Point of
CO❑Transportation
p by Common Shipment
Carrier Destination
El
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
'S Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/08/2022 Registrar of Vital Statistics Brenda L Peris(Electronically Signed)
(signature)
District Number 4553 Place Town Of Corinth
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:/
I—
Z Date of Disposition gt g I ZL Place of Disposition 'C „It._
W
2 (address)
W
t/)
O (section) /�R`,- (lot numb (grave number)
0 Name of Sexton or Person in Charge of Premises `/ ti �' f
Z /please print) �y�
W Signature Title riVirM lC
DOH-1555(07/18)p 1 of 2
i
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# • ''