Sicard, George Louis NEW YORK STATE DEPARTMENT OF HEALTH @Buri Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
George Louis Sicard Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/28/2022 71 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 19 George Street,Queensbury Town, New York 12845
p Manner of Death a Natural Cause ❑Accident 0 Homicide Suicide Undetermined ri Pending
W Circumstances Investigation
W Medical Certifier Name Title
G John Quaresima MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 165
X Burial Date Cemetery,Crematory or Facility Name
11/05/2022 Pine View Cemetery
Entombment
_ Address
Cremation Queensbury,New York
Donation
o❑Removal Date Place Removed
and/or and/or Held
NHold Address
0
O. Date Point of
N Transportation Shipment
p by Common
Carrier Destination
Disinterment
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
- Remains are Shipped,If Other than Above
Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/02/2022 Registrar of Vital Statistics Caroline ifiCfegarrfe Barber(ECectronically 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:
Date of Disposition \\• `i• a"D Place of Disposition a\ ( ua ,Q, �X\(.. 1 a �
W (address/
W JX-Au"\e_r-__C, 3 '''‘, Q
CC (secti (lot number) (grave number)
G Name of Sexton or Person in Charge of Premi es On n i 1 LDCd 7
(please print)
W Signature 414.4.4.
-. Title l r r l (l i <Xl )T
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
U I 2 95.1
Receipt
Human remains of - I . delivered on - , 20'
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• , ,:`,..- ,-
ti;401‘...e..-A,
Xne View Cemetery Representing the funeral home named on burial permit
'Official Funeral Directors Reg.or License# ' , ,
SICARD F'
Lot No. 33 A
ddress 11 George St. Lake George NY 12845 Section No.
wner Mary C. Sicard Plot Seneca
Valhi v'n
ate 11/1/01
Approx. 200 Superficial ft.
Dcation Bounded on North by Woods, South by Vacant, East by Path, West by Path.
Drner Posts
emarks 1 9 a • Sq b 3
eed No. (and changes) 3146
ayment Record Paid in Full 11/1/01 ($2,400.00)
ecord of Interments
Charles Sicard 7/19/03
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irm No. 01
SICARD
NAME George Louis Sicar LF Age: 71
Lot Owner: Mary C. Sicard
Lot# Seneca 33 A Grave# 2
Case: Concrete
Died: 1 0.2 8.2 2 Interred:1 1 .5.2 2
Funeral Home: Sibgleton Sullivan Potter
Cemetery: Pine View