Horick, Darryl M „. . j,.........f) 4 CA lg
NEW YORK STATE DEPARTMENT OF HEALTH ir•_ __ Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Darryl M Horick Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/01/2022 54 Years War or Dates
H Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death ❑X Natural Cause Accident 0Homicide ESuicide Undetermined ❑Pending
0 Circumstances Investigation
WW Medical Certifier Name Title
O Melody Long PA
Address
100 Park Street,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 403
Burial Date Cemetery,Crematory or Facility Name
08/03/2022 Pine View Crematory
Entombment— Address
lICremation Queensbury Town,New York
Donation
O Removal Date Place Removed
and/or and/or Held
E- Hold Address
U) Transportation Date Point of
$ by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
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
Remains are Shipped,If Other than Above
Address
4 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/03/2022 Registrar of Vital Statistics Megan Wolin(ECectronica1TySigned)
I /signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W
Date of Disposition 214 111 Place of Disposition ..,,,� A----
g (address)
W
CO (section) / *number) (grave number)
Name of Sexton or Person in Charge of ises r` y__, �( e print)
W IN
Signature Title r�yrn ii
DOH-1555(07/18)p 1 of 2
. ALL' 1 rw� ,;
Public Health Law Sec. 4145(2b)
1
1 Receipt
1
Human remains of delivered on , 20
1
1
1 Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#