Serlin, Stephen 4 '
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Stephen Marc Serlin Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/13/2018 77 Years War or Dates
#- Place of Death Hospital, Institution or
cf, City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death a Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Farhana Kamaf MD
Address
100 Park St,Glens Falls,New York 12801
k:,' Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 437
x ®Burial Date Cemetery or Crematory
09/17/2018 Pine View Cemetery
0 Entombment Address
OCremation Queensbury, New York
Date Place Removed
Z O Removal and/or Held
and/or Address
t Hold
-40
0 Date Point of
O Transportation Shipment
C by Common Destination
Carrier
M0 Disinterment Date Cemetery Address
O Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
; Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
Address
Ile
Al
CI. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/14/2018 Registrar of Vital Statistics Wc6ertA Curtis(E(ectrouica((ySigned)
(signature)
District Number 5601 Place Glens Falls, New York
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition 9/1 7/201 8Place of Disposition Pine View Cemetery Queensbury
W (address)
U) Adirondack 2 & 15 3
Le (section) (lot number) (grave number)
pName of ton or Person in Charge of Premises Connie L. Goedert
Z �p (please print)
W Signatu tutuf`' Title Cemetery Superintendent
(over)
DOH-1555(02/2004)