Pickett, Floyd ,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
;.. Name First Middle Last Sex
Floyd Edgar Pickett Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 5, 2016 101 War or Dates World War II
Place of Death Hospital, Institution or
;F City, Town or Village Village of Granville,NY Street Address Indian River Nursing Home
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
D` - Qadl 1 NO
• +�Add ss
cr\vl` i
} Death Certificate Filed District Number)(2 Register Number
City, Town or Village Village of Granville, NY (-2—
❑X Burial Date Cemetery or Crematory
April 11, 2016 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road Queensbury, Queensbury,NY 12804
Date Place Removed
= Removal and/or Held
and/or Address
0{ Hold
V);
0 Date Point of
cTransportation Shipment
a 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 01443
Address
53 Quaker Road, Queensbu ,NY 12804
Name of Funeral Firm Making Disposition or to Whom
.y Remains are Shipped, If Other than Above
�=1 Address
Permission is hereby granted to dispose of the human rema • . -sc '• - . iii ove as indicated.
0 Date Issued -r/7 l i(p Registrar of Vital Statistics v`+ �/
r (signature)
'r District Number 75 Place Y t l Vqe ®-P- arvcsu,t �I,�l�
4 l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 4/11 /1 6 Place of Disposition Pine View Cemetery, Queensbury, NY
W (address)
S. I. #2 83 1
(section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises Connie L. Goedert
Z (please print)
W. natur Si /4--A--e-C,g Title Cemetery Superintendent
(over)
DOH-1555(02/2004)