Callanan, Scott David r (rLE T
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Scott David Callanan Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/27/2022 49 Years War or Dates Navy
1,,. Place of Death Hospital,Institution or
W City,Town or Village Fort Ann Town Street Address 1742 Pilot Knob Road, Fort Ann Town, New York 12827
p Manner of Death a Natural Cause Accident E Homicide Suicide nUndetermined riPending
W Circumstances Investigation
W Medical Certifier Name Title
ill John Aiken Coroner
Address
40 Burquist Road,Fort Ann Town,New York 12827
Death Certificate Filed Town Of Fort Ann District Number Register Number
City,Town or Village 5754 24
Burial Date Cemetery,Crematory or Facility Name
11/30/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
p Hold Address
0
a Date Point of
f/)0 Transportation Shipment
b by Common
Carrier Destination
Disinterment Date Cemetery Address
CI
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
ki 407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
i... Remains are Shipped,If Other than Above
a Address
Q
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/29/2022 Registrar of Vital Statistics JenniferJack,con(E(ectronica1tySigned)
(signature)
District Number 5754 Place Town Of Fort Ann
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 6........,
Date of Disposition I2Iz( it Place of Disposition .,,IL
W address/
W
CC (section) A (loj nu mberj (grave number)
8 Name of Sexton or Person in Charge of Premises ' r�it
(pl se print)
W T
� l' -m►1 it
Signature Title
DOH-1555(07/18)p 1 of 2
J
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#