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Sullivan, John Robert Jr. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John Robert Sullivan Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 10/29/2023 85 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Chester Town Warren Street Address 179 Ben Culver Road,Chester Town Warren,New York 12817 UJ 1p Manner of Death El Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title G Autumn Webb PA Address 102 Park Street,Glens Falls,New York 12801 Death Certificate Filed Town Of Chester District Number Register Number City,Town or Village 5652 19 Burial Date Cemetery,Crematory or Facility Name 10/31/2023 Pine View Crematory _Entombment Address ©Cremation Queensbury Town,New York Donation ZZ❑Removal Date Place Removed and/or and/or Held H Hold Address 0 O. Date Point of N Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom ▪ Remains are Shipped,If Other than Above 5 Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/31/2023 Registrar of Vital Statistics Mindy Conway(Etectronicatcy Signed) (signature) District Number 5652 Place Town Of Chester I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: t— W Date of Disposition �I 12113 Place of Disposition j'p6,J (�?;4'1"; �u... 2 (address) W CC (section) � (lot number) (grave number) SName of Sexton or Person in Charge of Pre ' es ' � u"4 tr Z ( ease print) W Signature Title `Q' 7-6 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#