Lopez, Renaldo "' NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Renaldo Lopez Male
• Date of Death Age If Veteran of U.S. Armed Forces,
12/27/2018 67 War or Dates
Place of Death Hospital, Institution or
2 City, Town or Village Ft. Ann Street Address 11274 State Rt 149
W Manner of Death 0 Natural Cause Accident Homicide ❑Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
a Wesley Perry Coroner
Address
26 Mettowee Street,Granville,NY 12832
Death Certificate Filed District Number Register Number
City, Town or Village 51 S Lf 14
®Burial Date Cemetery or Crematory
January 2,2019 Pine View Cemetery
Address
❑Cremation Quaker Road,Queensbury,NY 12804
Date Place Removed
Z ri Removal and/or Held
and/or Address
H Hold
U)
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
El
Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
1 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 Other than Above
• Address
u. Permission is hereby granted to dispose of the human remains describedabove as indicated.
Date Issued I - 2-19 Registrar of Vital Statistics � u .w�� Le../lI'
(signature)
District Number 5'") 59 Place w rl d-r i U t'-/-- A A s'1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uiDate of Disposition 1 /2/2 01 9 Place of Disposition p; n P Vi ew Cerro.,tQrdy Que' shnry
W (a dress)
N Seneca 32-A 1
IX (section) (lot number) (grave number)
p Name of Sex n or Person in Charge of Premises Connie L. Goedert
Z (please print)
W Signature dRa,z �- e. Title Cemetery Superintendent
i
(over)
DOH-1555(02/2004)