Rawlins Jr., Anthony NEW YORK STATE DEPARTMENT OF HEALTH
SVitalcords Section Burial - Transit Permit
Name First Middle Last Sex
Anthony Robert Rawlins Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
F. January 4, 2006 24 War or Dates
Z Place of Death Hospital, Institution or
W City, Town, or Village Glens Falls Street Address Residence
G Manner of Death oft Jatural Cause Ei, Accident LI Homicide ESuicide El Undetermined Pending
l Circumstances Investigation
Medical Certifier Name m C c Title
Q Address ' - 1
cis
Death Certificate Filed District nt
mb Register Number
City, Town or Village Glens Falls ,5
0 Burial Date Cemetery or Crematory
January 10, 2006 Pine View Cemetery
❑ Entombment Address
❑ Cremation Quaker Road Queensbury, NY 12804-
Date Place Removed
0 Removal and/or Held
am and/or Address
i'' Hold
Date Point of
0 n Transportation Shipment
A by Common Destination
i Carrier
Date Cemetery Address
6 0
Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Service 01519
Address
53 Quaker Rd. , Queensbury, New York 12804
2 Name of Funeral Firm Making Disposition or to Whom
Cr
Remains are Shipped, If Other than Above
W Address
O.
Permission is hereby granted to dispose of the human remains describ d above as_indic d.
Date Issued Z f ti / U G Registrar of Vital Statistics 4
(signatur�
District Number 5hC' ) Place Glens Falls,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 01/10/2006 Place of Disposition Pine View Cemetery
2 (address)
0 MOHICAN 20-F 1
o (section) (lot number) (grave number)
CName of Sexton or Person in Charge of Premises M I CHAEL GEN I ER
Z (please print)
W
Signatur91AAM4.0%., Title SUPT.
(over)
DOH-1555 (02/2004)