Crossman, Daniel c s #� 3L�
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Daniel W. Crossman Male
iv
Date of Death Age If Veteran of U.S. Armed Forces,
May 4, 2017 66 War or Dates Vietnam
: ,' Place of Death Hospital, Institution or
, - City, Town or Village Glens Falls,NY Street Address The Pines At Glens Falls
Manner of Death n Natural Cause ❑Accident n Homicide Suicide n Undetermined n Pending
Circumstances Investigation
•
Medical Certifier Name Title
Melissa Decker MD
Address
9 Carey Rd.Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village 56C I Zb
•
❑Burial Date Cemetery or Crematory
May 5,2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ElRemoval and/or Held
and/or Address
Hold
Cl)
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
x* Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
- Address
Permission is hereby granted to dispose of the human remains d/ a r'be al;gve Gated.
•
:51, Date Issued 2 5/05/?.F,i/7 Registrar of Vital Statistics
/ (signature)
xl District Number J 60/ Place c �`/ , AV
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition Silo Ir Place of Disposition .170 V4.S i rn toe '-
2 (address)
U)
O (section) /-, (lot number) C (grave number)
Q Name of Sexton or Person in Charge of Premises C hr itr J cnnl It
'Z (pl print)
Signature L' —1 Title
(over)
DOH-1555(02/2004)