Daley, George NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George Daley Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 11, 2014 65 War or Dates
�.. Place of Death Hospital, Institution or
Z City, Town or Village Warrensburg Street Address 3810 Main Street
QManner of Death I TI Natural Cause n Accident n Homicide ❑Suicide Undetermined n Pending
Circumstances Investigation
G Medical Certifier Name Title
Robert Sponzo
Address
Cancer Center, 102 Park St,Glens Falls,NY 12801
Death Certificate Filed Town of Warrensburg District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
❑Entombment
Address
❑Cremation
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
Hold
U)
aDate Point of
co n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
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
I- Remains are Shipped, If Other than Above
2 Address
W
Permission is reb granted to dispose of the huma - • . - describ bove as indicated.
Date Issued l Registrar of Vital Stati '�i7z _-;
(signature)
District Number 570.6 Place Town of Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LLI Date of Disposition 1 /1 7/1 4 Place of Disposition _ Pine VIew Cemetery
W (address)
N Huron 23 E 1
(section) (lot number) (grave number)
Q Name of Se on or Person in Charge of Premises Connie L. Goedert
(pleasep rint)
uu 'L Superintendent
Signature w(L� Title
(over)
DOH-1555(02/2004)