Herman, Stephen 5(42
NEW YORK STATE DEPARTMENT OF HEALTH I i, #
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Stephen Herman Male
Date of Death Ape If Veteran of U.S.Armed Forces,
November 25,2006 78 War or Dates WWII
i•- Place of Death City of Glens Falls Hospital, Institution or Glens Falls Hospital
Z City, Town or Village Street Address
W Manner of Death CX Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
® Circumstances Investigation
ill
Medical Certifier Name Title
W Michael Adams MD
CI Address
10154 Saratoga Rd.Ft.Edward NY 12828
Death Certificate Filed District Number Register Numbbeer,
City, Town or Village Glens Falls 5601 Y
0 Burial Date Cemetery or Crematory
11/27/2006 Pine View Crematorium
❑ Entombment Address
0 Cremation Queensbury,NY
Date Place Removed
z ❑ Removal and/or Held
p and/or Address
F- Hold
N Date Point of
a ❑ Transportation Shipment
CO by Common Destination
G Carrier
Date Cemetery Address
n Disinterment
Date Cemetery Address
❑ Renterment
Permit Issued to Registration Number
Name of Funeral Home Regan&Denny Funeral Home 01520
Address
94 Saratoga Avenue,South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
pPermission is he ebv ranted to dispose of the human r mains d cribed a ove as indi ated.�
Date Issued Registrar of Vital Statistics
signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZDate of Disposition (I /.21/6 b Place of Disposition P,Ivi v t t w CreArr.4k c:r iv r►-
W (address)
2
W
(section) (lo umber) (grave number)
Name of Sexton or Person in Charge of Premises C/ r's eiYt-t'ti"
°f (please print)
ignature CL 4 '' Title Cce"cio'r
555 (02/2004) (over)