Barbieri, John Louis jr. c Li-- ' .
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NEW YORK STATE DEPARTMENT OF HEALTH `,.. -- Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Louis Barbieri Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/11/2022 45 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
O Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
111
Circumstances Investigation
0W Medical Certifier Name Title
O Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 572
ElBurial Date Cemetery,Crematory or Facility Name
11/15/2022 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
DDonation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
n. Date Point of
Cl)❑Transportation
0 by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
EI
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
2 Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/15/2022 Registrar of Vital Statistics Megan_Wain(E/ctronicay Signed)
(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:
F
Z Date of Disposition Hilo/7Z Place of Disposition '174\/ ,,."11-a---.
2 (address)
Ill)
0 (s n) //r (!ot n�umrber) (grave number)
0 Name of Sexton or Person in Charge remises
l/[1
Z ase print)
W Signature Title (e'Em'f
DOH-1555(07/18)p 1 of 2
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# -
1