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Cooper, Johnathan Marvin NEW YORK STATE DEPARTMENT OF HEALTH Burial — Transit Permit Bureau of Vital Records Name First Middle Last Sex Jonathan Marvin Cooper Male Date of Death Age If Veteran of U.S.Armed Forces, 06/16/2023 66 Years War or Dates 74-76 Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 162 Sunnyside Road,Queensbury Town, New York 12804 Manner of Death El Natural Cause Accident Homicide ESuicide FlUndetermined inPending W Circumstances Investigation W Medical Certifier Name Title CI Connie Goedert Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 92 Burial Date Cemetery,Crematory or Facility Name 06/23/2023 Pine View Crematory Entombment Address ©Cremation Queensbury,New York ❑Donation ❑Removal Date Place Removed and/or and/or Held N Hold Address 0 0. Date Point of N❑Transportation Shipment by Common Carrier Destination ODisinterment 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 5 Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/23/2023 Registrar of Vital Statistics CarolineJfi((egarde Barber(ECectronica((y 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: WDate of Disposition /z3173 Place of Disposition 2 (address) W CC CC (section) // (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premise Z j(lease print) �� �,,� W Signature Titlec �`—'r DOH-1555(07/18)p t 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# •