Modeen, Stanley NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
VI Name First Middle Last Sex
i
Stanley E.Modeen 11 Male 1
Date of Death 1 Age If Veteran of U.S. Armed Forces,
05/04/2018 [86 Years War Or Dates Korean War
`'` Place of Death Hospital, Institution or
FilCity, Town or Village Glens Falls 1 Street Address Glens Falls Hospital
171,1 Manner of Death X Natural Cause [ 1 Accident L Homicide ! Suicide 1 Undetermined Pending
El
— a
Circumstances Investigation
Medical Certifier Name Title
Shahid Ahmed MD
Address
-; 100 Park St,Glens Falls,New York 12801
{� ' Death Certificate Filed District Number Register Number
1
g , City, Town or Village Glens Falls 5601 220
I_E t mlbment Date Cemetery or Crematory
a -- , 05/07/2018 PineView Crematorium
Address
4 5
X'Cremation Queensbury Town, New York
' 1 Date ; Place Removed
tit X,; Removal 1 and/or Held
and/or
Address
51°
° Hold
4i111 Date Point of
j Transportation Shipment
by Common Destination
Carrier
w, ! Disinterment Date Cemetery Address
j Reinterment AA Date Cemetery Address
s;
Permit Issued to ' Registration Number
0 Name of Funeral Home Mason Funeral Home , 01117
g : Address
1�
r 18 George St Po Box 277,Fort Ann, New York 12827-0277
1" ° Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w, Permission is hereby granted to dispose of the human remains described above as indicated.
wr
fv, Date Issued 05/07/2018 Registrar of Vital Statistics �6ertA Curtis(Electronically Signed)
(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:
Date of Disposition S/7/(q Place of Disposition i
(address)
i .
(section) il(lot number) (grave number)
0.
„, 9 ( _Name of Sexton or Person in Charge of Premises-_ 44 . Sa,.
ease print)
qz
2/
Signature 4-- Title 71)
(over)
DOH-1555 (02/2004)