Swinton, Wallace r \ i
NEW YORK STATE DEPARTMENT OF HEALTH 7.
Burial
Vital Records Section - Transit Permit
Name First Middle Last Sex
Wallace Lee Swinton Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/21/2018 69 Years War or Dates 1969-1970
IF= Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
la Circumstances Investigation
iii Medical Certifier Name Title
Stephen Perazzelli MD
Address
▪ 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 400
41❑Burial Date Cemetery or Crematory
08/27/2018 Pine View Crematory
-▪ ❑Entombment' Address
▪ ®Cremation Queensbury, New York
F` Date Place Removed
El Removal and/or Held
and/or Address
W Hold
r#
Date Point of
r❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Renterment Date Cemetery Address
#may 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
Remains are Shipped, If Other than Above
Address
iI
t" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/23/2018 Registrar of Vital Statistics clp6ertA Curtis(ECectronicaltySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent Identified above were disposed of in accordance with this permit on:
Z lit Date of Disposition ifM O Place of Disposition p�,�u.. 69,..4aw
U.1
(address)
0
Lt (section) lot number) (grave number)
aName of Sexton or Person in Charge of Premises fA L Si,err
Zr (please print)
114 di 4
Signature Title 1€t4i t t
(over)
DOH-1555 (02/2004)