Flint, Grover NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Grover:...:::............................,..::...:::.::..:.::...O.ert ....................: male
Date of Death Age If Veteran of U.S.Armed Forces,
..::.::.......1)ecernber:2,....1990 _ .......:: 59. ....
War or Dates
:Z Place of Death Hospital, Institution or
itil City Town or Village City of...Gle.ns::Falls ...,,, Street Address Glens.:.Falls...Hospitel. ..,.. ...............
W Manner of Death ® Natural Cause ❑ Accident Homicide Suicide 0 Undetermined ❑ Pending
Circumstances Investigation
itu Medical Certifier Name Title
....::.........................:..........................Da,vd...W.....Schwenker..: ,:.........:..: ..:.:MD....:......... .......: .:..:..:: .::...:�.::....: --
Address
....90....South....Street, Glens. Falls,...New... Q.rk...12801 ...: :
iiv Death Certificate Filed District Number Register Number
iiiW City,Town or Village City of Glens Falls
�Illv�1 Date Cemetery or Crematory
LaJBurial December 5,_ 1990 Pine View Cemetery
❑Cremation Address
z Date Place Removed
.0 0 Removal and/or Held
•F- and/or Hold
Address
(1)
0. ..�.:.. ....................._:.........................................:... :.::::...... ... . ::............ -. .....:. .. :..::..... .. .... :.....-. ..::. .
a Date Point of
cn 0Transportation by Shipment
p Common Carrier ..:...:.....................:.........._ ........::.... -:::::::.. .,:. __::::......:.._
Destination
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
El Permit Issued to Registration Number
Name of Funeral Firm Regan and Denny Funeral Service Inc 01634
Address
26 Quaker Road, Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
ili Remains are Shipped, If Other than Above
Address
la
Permission is hereby granted to dispose of the human remains escribed abo e as indicated.
Wii Date Issued Registrar of Vital Statistics �.o
` �/ U Re g /(signature)
District Number 310 0/ Place ,i17 )? /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i . p
Z ?Date of Disposition i -.-yr� Place of Disposition //� = //'lG—_ ,/ .c=.eft=f��'i:'>,J 1 e--c "nis"6i/25/a ii
La
(address)
La ti,,-r>,"//,? / O ea 7 /
: (section) (lot number) (grave umber)
p, Name of Sexto Person in Charge of Premises 71 o i>ii yr --- /ti`d S -tom
Z• (please print f
W Signature • 6''AR...o Title Sii/d%,
DOH-1555 (10/89) p. 1 of 2 VS-61