Spencer, Vincent NEW YORK STATE DEPARTMENT OF HEALTA
Vital Records Section Burial - Transit Permit
f Name First Middle Last Sex
Spencer 0Emmons Vincent Male
Date of Death Age If Veteran of U.S.ndiF,Kzes
August 4,2016 85 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls, Street Address The Pines At Glens Falls
Manner of Death
Medical Certifier Natural Cause n Accident 0 Homicide 0 Suicide Undetermined n Pending
Circumstances Investigation
Name Title
Melissa Decker MD
Address
;` 9 Carey Road,Queensbury,NY 12804
f>-r; Death Certificate Filed District Number'' J RegisteOuumb r
City, Town or Village ( / j9Y.
0 Burial Date Cemetery or Crematory
❑Entombment August 8,2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZO ri Removal and/or Held
and/or Address
F' Hold
y
O Date Point of
NLi Transportation Shipment
p by Common Destination
Carrier
Q Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Crermit Issued to
���, Registration Number
`r 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
t
:;fi: Permission is hereby granted to dispose of the human remains de ribed above a d' ated.
'f f Date Issued ya8/20/4 � Q `
� QRegistrar of Vital Statistics P
(signature)
District Number 5Z 0/ Place 6/s, /t/P,� Vi."--4—
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Paiftel
tu Date of Disposition g/iil�. Place of Dispositione ,.,,
W (address)
CO
piZ (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ICE
Z I(please print)
W Signature �y� Title C1 2
(over)
DOH-1555(02/2004)