Hubbell, Boy NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Twin B - Boy Hubbell male
Date of Death ;; Age If Veteran of U.S. Armed Forces,
3-4.92 fetus War or Dates no
Z Place of Death Hospital, Institution or
W City,Town or Village city of Glens Falls Street Address Glens Falls Hospital
1 Manner of Death El Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
L13 Medical Certifier Name Title
Q,,,,:,: J. O'Keeffe M.D. Medical Physician
Address
45 Hudson Ave Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village City of Glens Falls Je
Date Cemetery or Crematory
®Burial 3 9 92 Seeley Cemetery
emeter
['Cremation Address
Queensbury, NY 12804
z Date Place Removed
0 0 Removal and/or Held
F- and/or Hold :::.. ...
Address
U)
0
a Date Point of
cn' ❑Transportation by Shipment
p' Common Carrier
Destination
❑ Disinterment Date Cemetery Address
. .......... ....
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Regan & Denny_ Funeral Service,.:: Inc, 01.602: -......... . .::....:::::..:
Address
.... 26 Quaker:..Road,.::Queensbury,:::NY..:: ::12DQ4
14. Name of Funeral Firm Making Disposition or to Whom
`-2i Remains are Shipped, If Other than Above
tr
Address
w.
s1
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3/9 l Registrar of Vital Statistics Ci4 & LO -644-AL1 /(,-
(signature) / g��
District Number( 6 a Place ee.....c,...), s...e.e....„...2, i /2„, "
_...
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ /j
W' Date of Disposition )-/- „'_ Place of Disposition a- r �z r_-_y Cam'`"_i'-;/_ /r�(.'/j L .,;-i,-,4,:,, i.1,,„=/; ,
2 (address) _
W' 4/f%I/ /`4 1 /
cn
IX (section) (lot number) (grave number)
O
g Name of Sext Person in Char a of Premises ,-;-" („,,,-.,,/,-- /- -/ ' :5 /7L--
Z � (please print)
W Signature�,� a,�-A i , _era,_..-a�.�, Title , , / ,
DOH-1555 (10/89) p. 1 of 2 VS-61