Penman, Gary NEW YORK STATE DEPARTMENT OF HEALTH 4' 11
Vital Records Section Burial - Transit Permit
Name First i Middle Last Sex
Gary F Stewart Penman Male
Date of Death AgA1 If Veteran of U.S. Armed Forces,
.. January 11, 2017 64 War or Dates n/a
:4 Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death r—li i Natural Cause ❑Accident ❑Homicide ❑Suicide 1-1 Undetermined n Pending
'• Circumstances Investigation
Medical CeMier Name Title
...:1, Glecr,s ildress ,
Death Certificate Filed �� District Number Register Number
k City, Town or Village Glens Falls,NY 5601 2
❑Burial Date Cemetery or Crematory
❑Entombment January 13,2017 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z EIRemoval and/or Held
and/or Address
H Hold
Cl)
O Date Point of
It n Transportation Shipment
5 by Common Destination
Carrier
El
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
` , Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
t.
Address
". 94 Saratoga Avenue, South Glens Falls,NY 12803
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 human remains described abo as i ated.
Date Issued 01/2120/7 Registrar of Vital Statistics
(signature)
District Number J 6.0/ Place �� a; , N
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition I h lal r) Place of Disposition fritf,),,,✓ et, {-o<<.,
W (address)
Cl)
IX (section) (lot number) ( (grave number)
Z Name of Sexton or Person in Charge of Pre ises Ora '
(pl se print)
W
Signature Title CkmtiR&
(over)
DOH-1555(02/2004)