Zerbst, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First MidgIe Last Sex
JOHN DOUGLAS ZF:PBST Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 31 , 2016 67 War or Dates n/a
-•. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
0 Manner of Death❑Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined �Pending
t11 Circumstances Investigation
tu Medical Certifier Name Title
0
Address
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls, NY 5601
❑Burial Date Cemetery or Crematory
June 2, 2016 Pine View Crematory
❑Entombment Address
j a,Cremation Queensbury, NY
Date Place Removed
Z❑Removal and/or Held
Y. and/or Address
V
Hold
O Date Point of
Transportation Shipment _
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment 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
Remains are Shipped, If Cther than Above
Address
tr
tt
Permission is hereby granted to dispose of the human remains d scribed above i dicated.
iii
il Date Issued 6/2/2016 Registrar of Vital Statistics 4iit sa
Lti
(signature)
District Number 5601 Place City of Glens Falls, NY 12801
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E �t� 6Date of Disposition it,lib Place of Disposition t� � �,M�►w1"r�,
(address)
la
aCC (section) (I t'n11umtt ber) (grave number)
Name of Sexton or Person in Charg of Premises Arir iyL.)1 !-
4 (pl se print)
ill
Signature Title aki.mitiot
(over)
DOH-1555 (02/2004)