Heym, Henry NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Henry N Heym Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 4, 2014 80 War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death I XI Natural Cause I I Accident Homicide Suicide I 'Undetermined 1 Pending
Circumstances Investigation
Medical Certifier Name Title
:.;•. Andrew Garner,MD
v: Address
8 Harrison Ave. Glens Falls,NY 12804
Death Certificate Filed District Numbe/6
r, Register Number
••
City, Town or Village Glens Falls ,.IJ Burial Date Cemetery or Crematory /
❑Entombment July 9,2014 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
Z i I Removal and/or Held
and/or Address
- Hold
aDate Point of
N I I Transportation Shipment
a by Common Destination
Carrier
I Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
E:: ‘ Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
'• Remains are Shipped, If Other than Above
Address —
if; Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued -/7 ( 16' Registrar of Vital Statistics _ U.)GA. LA)_
(signature) UUU
District Number S G Q / Place Glens Falls i Al
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tu Date of Disposition 7/9/1 4 Place of Disposition Pine View Cemetery
W (address)
Huron 4((fi�g 3
fr
Q (section)'Connie L L. G02Ci t n�utnber) (grave number)
p Name of Sexton or Person in Charge of Premises L
(please print)
W Signature L/K Title r---
Superintendent
(over)
DOH-1555(02/2004)