Jones, Walter NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Walter Lee Jones 1 Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 16, 2012 51 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
aManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
tit Circumstances Investigation
W Medical Certifier Name Title
a Daniel Way,MD
Address
100 Park Street Glens Falls,NY 12801
Death Certificate Filed District Numbe5601 ! Register Number
City, Town or Village Glens Falls 3 8y
❑X Burial Date j Cemetery or Crematory
August 21, 2012 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date ! Place Removed
Z Removal and/or Held
O and/or Address
H Hold
N
0 I Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Stafford Funeral Home 1 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
re
CL
Permission is hereby granted to dispose of the human remains described above as indic e .
Date Issued 08 Zc`ZD/2_ Registrar of Vital Statistics "i24 _,/,&.
/ (signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�
8/21 /12 Date of Disposition Place of Disposition Pine View Cemetery
W (address)
(n Free Ground Hudson Sec. 1 Lot 25 g. 1
CC
0 (section) (lot number) (grave number)
pName of Sexton or Person i�"�Charge of Premises Michael Genier
Z - - (please print)
W
Signature i`, SM >�- Title Superintendent
(over)
DOH-1555(02/2004)