Hermance, Herbert A Jr. # 21
NEW YORK STATE DEPARTMENT OF HEALTH \. ---/' Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Herbert A.Hermance Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/02/2023 67 Years War or Dates
▪ Place of Death Hospital,Institution or
2 City,Town or Village Glens Falls Street Address Glens Falls Hospital
111
W Manner of Death ❑X Natural Cause IllAccident Homicide Suicide Undetermined Pending
Circumstances Investigation
Ui Medical Certifier Name Title
O Kyle Leonard MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 3
Burial Date Cemetery,Crematory or Facility Name
01/04/2023 Pine View Crematory
Entombment Address
IIICremation Queensbury,New York
Donation
Z ElRemoval Date Place Removed
and/or and/or Held
I- Hold Address
N
0
O. Date Point of
N ETransportation Shipment
G by Common
Carrier Destination
Date Cemetery Address
Disinterment
El
Re interment
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
j.. Remains are Shipped,If Other than Above
S Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/04/2023 Registrar of Vital Statistics Megan.No(in(EhctronicaC(ySigned)
(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:Date of Disposition /_7 ZoZ 3 Place of Disposition ', de (Ji e�1 (r. /cJ a!'-
ILI
2 (address)
W
N LC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of remises p J, 7) ivie)
Z (please print)
W Signature I— .lid // 4 Title Oe�.,"4.4e
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#