Pond, Samuel NEW YORK STATE DEPARTMENT OF HEALTH r t 1 Z.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Samuel David Pond Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 31,2017 52 War or Dates n/a
ZPlace of Death Hospital, Institution or
City, Town or Village Glens Falls,NY Street Address 84 Lawrence Street,Apt A
0 Manner of Death l X l Natural Cause ❑Accident ❑Homicide pi Suicide ❑Undetermined n Pending
is Circumstances Investigation
W Medical Certifier Name Title
Dr Tedesco,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 1
❑Burial Date Cemetery or Crematory
❑Entombment November 6,2017 Pine View Crematory
Address
®Cremation Queensbury,NY
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑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
1 Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
Address
iU
Permission is he eb granted to dispose of the humanas • dic= ed.
Date Issued J J / in describe above/Registrar of Vital Statistics pf_��\/ / 12(
(signature)
District Number 5601 Place ity of Glens Falls,New York 12801
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition /I j 7(n Place of Disposition Fa ✓ (.+'recii(fit.,.✓
W (address)
U)
W (section) (lot number) - (grave number)
Q Name of Sexton or Person in Charge of Premises t,,, S s,,,iii
Z (pl ase print)
W
Signature Title ("nin
(over)
DOH-1555(02/2004)