DeWitt, Ralph NEW YORK STATE DEPARTMENT OF HEALTH
.VitalRcords Section Burial - Transit Permit
Name First Middle Last Sex
Ralph W. _ De Witt Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 11,2011 97 War or Dates No
iPlace of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 16 Masters Common North
ci Manner of Death X Natural Cause n Accident n Homicide E Suicide n Undetermined Pending
di Circumstances Investigation
Medical Certifier Name Title
P.: William Borgus Dr.
Address
14 Manor Drive,Queensbury,NY 12804
:::1 Death Certificate Filed District Number Register rriber
,., City, Town or Village Queensbury 5657
®Burial Date Cemetery or Crematory
August 20,2011 Pine View Cemetery
D Entombment Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
F" Hold
N
0 Date Point of
N ri Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
iE;+ Remains are Shipped, If Other than Above
Address
gi
Permission is hereby granted to dispose of the human re ins r1escrib d a - ve as indicated.
Date Issued R- IZ��o�t Registrar of Vital Statistics ,'
(signatu�)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z 8 20 Pine View Cemetery
of Disposition �11 Place of Disposition
W (address)
CC Mohican 90 D 1
rt (section) (lot number) (grave number)
pName of Sexton or Person ' Charge of Premises Michael Genier
z (please print)
W Signaturea.aj Title Superintendent
(over)
DOH-1555(02/2004)