Pond, Wayne s �1 37 7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
;r Wayne T. Pond Male
Date of Death Age If Veteran of U.S. Armed Forces,
i$` May 4, 2017 65 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 63 Connecticut Ave
9,
.: Manner of Death ! Natural Cause n Accident )Homicide ❑Suicide )Undetermined 1-1 Pending
: Circumstances Investigation
.'f Medical Certifier Name Title
Christopher D.Hoy
Address
161 Carey Road,Glens Falls,NY 12801
Death Certificate Filed District Number egist r Number
City, Town or Village Queensbury 5657
❑Burial Date Cemetery or Crematory
❑Entombment May 10, 2017 Pine View Crematorium
Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
0 n Removal and/or Held
and/or Address
Hold
CO
0O.` Date Point of
fa ❑Transportation Shipment
p by Common Destination
Carrier
pi Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
% ; 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
:: Remains are Shipped, If Other than Above
` • Address
Permission is hereby granted to dispose of the huma rdesc
ribed bove as indicated.
Date Issued l Registrar of Vital Statistics C----- ---:1 V
_ r(signatue)
District Number 5657 Place Queensbury
.r• :
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
u Date of Disposition 5112 In
1n Place of Disposition 'f c t.ea+o .e W (address)
N
p0 (section) / (lot number) ( (grave number)
' Name of Sexton or Person in Charge of Premises Ar.hav J ..-1( '
Z (Abase print)
W Signature �/ Title `Ivy Mt j71
(over)
DOH-1555(02/2004)