Martindale Sr., Floyd I.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit •
n
IiiiN Name First Middle Last Sex
Floyd IL Martindale Sr_ male
11 Date of Death 8/1 5/2 01 1 Age 9 2 If Veteran of U.S.Armed Forces, •
War or Dates n/a
A Place of Death Hospital, Institution or
2 City, Town or Village Queensbury Street Address Stanton Nursing Home
Manner of Death®Natural Cause 0 Accident 0 Homicide Q Suicide nUndetermined ri Pending
t Circumstances Investigation
til Medical Certifier Name • Title
Roslyn Socolof, MD
0 Address
ii Sherman Ave. Queensbury NY
Death Certificate Filed Dis icctt��NNum�ber Re ter Number
City,Town or Village
Date Cemetery or Crematory
®Burial 8/19/2011 Pine View Cemetery
Address •
❑Cremation .Queensbury, NY
•
Date Place Reriioved
0 El Removal and/or Held
M and/or Address
a Hold •
2 Date Point of
?l El Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan and Denny Funeral Home 01 443
Address
53 Quaker Rd. Queensbury, NY 12804
NaName of Funeral Firm Making Disposition or to Whom
reare' Remains are Shipped, If Other than Above
41 Address •
W •
Permission is herebygranted to dispose of the human remains described above as indicated.
;�f:; P
igi Date Issued 53 1. 1 (.D la01) Registrar of Vital Statistics .,, 01 _ (),,L,�
in (sig ture)
iii District Numbe .o Place / 6 c�-sz a '� \ x_P�v�.Sb�,t .
}
I certify that the remains of the decedent identified at5ove were disposed of in accordan a ith this permit on:
f
• Date of Disposition 8/19/11 Place of Disposition Pine View Cemetery
(address)
Unadil1a Ext . 15 3
t (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises Michael Genier
j I - (please print)
'1 Signature .Ri—A, Title Superintendent
(over)
1555 (9/98)