Certain, Alexander NEW YORK Sx ATElhEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alexander Certain Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 7, 2011 79 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls I Street Address Glens Falls Hospital
pManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
w Circumstances Investigation
w Medical Certifier Name Title
Christopher Hoy,MD
Address
102 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls S Q f S 3
Burial Date Cemetery or Crematory
January 13, 2011
❑Entombment Address
❑Cremation
Date Place Removed
Z Removal and/or Held
0 and/or Address
H Hold
rn
0 Date Point of
N Transportation Shipment
'p 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 01464
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2 Address
Ce
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued //i I/ ?o a / Registrar of Vital Statistics
(signature
District Number 5 Go Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 1/13/2011 Place of Disposition Pine View Cemetery
(address)
N Erie 55B 1
(section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises Michael Genier
Z (please print)
w Signature Title Superintendent
(over)
DOH-1555 (02/2004)