Dickenson, Craig •
t NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Craig D Dickenson Male
Date of Death Age If Veteran of U.S. Armed Forces,
9/19/2018 41 War or Dates
t- Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 54 Dixon Rd.
W Manner of Death � Undetermined Pending
O I^I Natural Cause Accident Homicide Suicide n
Circumstances Investigation
W Medical Certifier Name Title
O John Stoutenburg,MD
Address
102 Park Place,Glens Falls NY
Death Certificate Filed ` District Number Register Number
City, Town or Village Queensbury 5657 I''j
®Burial Date Cemetery or Crematory
September 29, 2018 Mount Herman
❑Entombment Address
❑Cremation Luzerne&West Mountain, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
U) - - -
O Date Point of
Nn Transportation _ Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
1-1
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
H Remains are Shipped, If Other than Above
2 Address
et
W
0. Permission is hereby granted to dispose of the human re a s describe v a ' di ted.
`'I ; 4 Date Issued � -a(p Registrar of Vital Statistics �( (signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z DispositionPlace of Disposition Mt. Hermon Cemetery Queensbury
Date of 9/2 9/2 01 8
W (address)
U)
IX (section) (lot number) (grave number)
pName of Se ton or Person 'n Charge of Premises Connie L. Goedert
z (please print)
Signature AD Nut r,. 0AL-teC Title Cemetery Superintendent
(over)
DOH-1555(02/2004)