Daley, Christopher NEW PORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
.: Name First Middle Last Sex
Christopher M. Daley Male
-::, Date of Death Age If Veteran of U.S. Armed Forces,
fa April 24, 2014 42 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Warrensburg Street Address 14 County Home Bridge Rd.
Manner of Death [ i Natural Cause I Accident Homicide Suicide Undetermined x Pending
Circumstances Investigation
Medical Certifier Name Title
Paul Bachman
e°:; Address
r 3767 Main Street,Warrensburg,NY 12885
r Death Certificate Filed District Number Register Number ? -,
:_::: City, Town or Village Warrensburg 5660
"Y 0 Burial Date Cemetery or Crematory
❑Entombment April 30, 2014 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
Zip n Removal and/or Held
and/or Address
F Hold
O Date Point of
u) Transportation Shipment
by Common Destination
Carrier
[ Disinterment Date Cemetery Address
L Reinterment Date Cemetery Address
',..% Permit Issued to Registration Number
::: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
ra::' 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 he eby ranted to dispose of the human remai described abo, as indic d.
Date Issued 0 /q Registrar of Vital Statistics / 8 M"'
:tir si nature
: District Number 5660 Place Warrensburg
I 00.
-
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
4/30/14
W Date of Disposition Place of Disposition Pine View Stafford
W (address)
N Seneca 3 I 1
re (section) (lot number) (grave number)
pName of Se n or Person in Charge of Premises Connie L. Goedert
Z (please print)
w g ��Z �• G. Superintendent
Signature - ,P Title
(over)
DOH-1555(02/2004)