Warner, William NEW YORK STATE DEPARTMENT OF HEALTH 4 tin
Vital Records Section Burial - Transit Permit
iiiiiii Name First Middle Last Sex
i;s William A. Warner male
:: Date of Death Age If Veteran of U.S. Armed Forces,
o.:.: 06/03/2018 60 War or Dates n/a
L Place of Death Hospital, Institution or
t : City, Town or Village Queensbury Street Address 420 Luzern Rd
4 Manner of Death I - Natural Cause ( I Accident Homicide I. Suicide Undetermined - Pending
Circumstances Investigation
v Medical Certifier Name Title
:-.'•} John T. Quaresima MD
Address
{; 160 Carey Rd, Queensbury NY
Death Certificate Filed Djstrriictt Number R e ister Number
r City,Town or Village 06/06/2018
❑Burial Date Cemetery or Crematory
06/06/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, NY
Date Place Removed
Removal and/or Held
0- and/or Address
t Hold
N
Q Date Point of
I 'Transportation Shipment
p by Common Destination
Carrier
I I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
y�.';:Y Permit Issued to Registration Number
. ' Name of Funeral Home Regan Denny Stafford 01443
i* Address
:'::' Queensbury NY INO-1 S2 (il utjYrW A+)
f Name of Funeral Firm Making Disposition or to Whom
;�:: Remains are Shipped, If Other than Above
r_ Address
{j Permission is hereby granted to dispose of the human remains described ove as indicated.
Date Issued I�l Registrar of Vital Statistics ).< �.Q Ii
Q (signature)
. District Number Place di Cr. c
I certify that the remains of the decedent identified above were disposed of in a ordance ith this permit on:
w Date of Disposition b/t tie Place of Disposition .:41."/ Oc•....
(address)
U,
g (section) ►ot number) (grave number)j Name of Sexton or Person in Charge of Premises '
(ple se print)111
x
Signature Title tr$i 1t'i
(over)
DOH-1555(02/2004)