Agney Jr., Malcolm '� ft 313
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Malcolm James Agnew Jr Male
Date of Death Age If Veteran of U.S. Armed Forces,
4/12/2018 60 War or Dates n/a
tPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 33 William Street
Manner of Death 0 Natural Cause n Accident Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Scott Miller,PA
Address
t' Glens Falls,NY
Death Certificate Filed District Number Registerfyupber
r. City, Town or Village Glens Falls,NY 5601 \
❑Burial Date Cemetery or Crematory
Entombment April 17,2018 Pine View Crematorium
11 Address
I Cremation 51 Quaker Road, Queensbury,NY 12804
Date I Place Removed
ZO 0 Removal _ and/or Held
and/or Address
H Hold
O Date Point of
co Transportation j Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
',_.=tj 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
iRemains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
k . Date Issued 44.116)2 ) iS- Registrar of Vital Statistics LA_t'.U...4y\12 W-'t-"
(signature)
District Number ,
�` ( Place 6 u.ev s \\s ' 'o
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
11,1 Date of Disposition 4 h I'1 I\' Place of Disposition 11e (0-14--
W (address)
co
(section) /1 (lot number) (grave number)
pName of Sexton or Person in Charge of Premises (,�r., Sa.,.iIT
tZ U 1 (pl se print)
Signature L( Title 1?fl in,
(over)
DOH-1555(02/2004)