Senecal, George H. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
George H.Senecal Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/18/19 92 War or Dates WWII
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Street Address 151 Sherman Island Road
p Manner of Death Natural Cause Accident Homicide ❑Suicide ❑Undetermined Pending
LLJ0 Circumstances Investigation
U
WQ Medical Certifier j me Title
I CA
Address
Fort Edward, NY
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury
Burial Date Cemetery,Crematory or Facility Name
') Pine View Crematory
Entombment Address
®Cremation Queensbury, NY
Donation
z Removal Date Place Removed
and/or and/or Held
~ Hold Address
t�
O
IL Date Point of
N ❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Fuenral Home, Inc. 00211
Address
24 Church St.,Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
Q
W
IL Permission is hereby granted to dispose of the human re ins describe ab e s indicated.
Date Issued 11/20/2019 Registrar of Vital Statistics1 T�
/ na /
District Number GJ Place Town of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 11 I-jo Place of Disposition
W (address)
2
W
X /section/ OJ� )lot nTtotir
(grave number)
Name of Sexton or Person in Charge of Premises 6 �r
U.1 �� q /Please print/ L
Signature JA^{�� Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013095
Receipt
Human remains of delivered on , 20
Pine View Cemetery �r Representing the funeral home named on burial permi
Official Funeral Directors Reg.or License#