Floyd, Martin --4.,NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
;3. Name First Middle Last Sex
Martin Floyd Male
r Date of Death Age If Veteran of U.S. Armed Forces,
'33 August 30, 2014 63 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 88 Gregwood Circle
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
pEMedical Certifier Name Title
IV David Cunningham Dr.
Address
::K3 3 Irongate Center,Glens Falls,NY 12801
3 Death Certificate Filed District Number Register Number
. City, Town or Village Queensbury 5657 t C1 LI
❑X Burial Date Cemetery or Crematory
❑Entombment September 4, 2014 Pine View Cemetery
Address
LI Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
h Hold
co
O Date Point of
yI (Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
; 3333 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
w
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued' I .--I,01 y Registrar of Vital Statistics c LIP-),L.,62
(signature) ____.„,
:: District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 9/4/14 Place of Disposition Pine View Cemetery
2 (address)
W
to Erie 13 B 2
tY
(section) (lot number) (grave number)
Q• Name of Se ton or Person in Charge of remises Connie L. Goedert
Z (please print)
W Signatur e 6/.1 Title Superintendent
(over)
DOH-1555(02/2004)