Norton Jr., Matthew t be11 q0
NEW YORK STATE DEPARTMENT OF HEALTH �Vital Records Section Burial - Transit Permit
Ater
Name First Middle Last Sex
Matthew Vincent Norton,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 9, 2017 72 War or Dates Yes
:.`r. Place of Death Hospital, Institution or
±: City, Town or Village Grandville Street Address Haynes House Of Hope
Manner of Death ❑X Natural Cause ❑Accident u Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
` Medical Certifier Name Title
Suzanne Blood,MD
ilii
Address
161 Carey Road,Queensbury,NY 12804
Death Certificate Filed District Number 5;..75� Register Number
t City, Town or Village Granville I
❑Burial Date Cemetery or Crematory
❑Entombment January 12, 2017 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z El Removal and/or Held
and/or Address
Hold
471
O Date Point of
A.
in n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
r Name of Funeral Home Regan Denny Stafford Funeral Home 01443
;iiiiiii Address
agi: 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 human remains described above as indicated.
IiiN Date Issued V(R i aD 17 Registrar of Vital Statistics c
" (signature)
as
District Number 575tv Place Granville
I certify that the remains of the decedent identified above were disposed of tin accordance with this permit on:
gDate of Disposition V/7//7 Place of Disposition /? 2 U f 2 frd GO'Qenc. /�✓
Li)
/ (address) /
N
p0 (section) \ /� (lot number) (grave number)
' Name of Sexto r n in Charge of Premises --hi. /, .✓1 .-.,•✓tc,e-he
Z (please print)
W Signature Title C/a f/ 0/0/2e ,74,
(over)
DOH-1555(02/2004)