Van De Ende, Etienne NEW YORK STATE DEPARTMENT OF HEALTH �7
Vital Records Section Burial - Transit Permit
a Name First Middle Last Sex
sg'.a Etienne Van De Ende Male
.: Date of Death Age If Veteran of U.S. Armed Forces,
August 6,2016 55 War or Dates
Place of Death Hospital, Institution or
Z: City, Town or Village Glens Falls Street Address Glens Falls Hospital
ci. Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
III 0-
Circumstances Investigation
w1 Medical Certifier Name Title
John Stoutenberg
Address
7h 102 Park Street,Glens Falls,NY 12801
] Death Certificate Filed District Number Register tuber
City, Town or Village ,__---6 Q / 7 2 7
❑Burial Date Cemetery or Crematory
❑Entombment August 9,2016 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
t Hold
0 Date Point of
y Ti Transportation Shipment
c3 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
_. Address
3809 Main Street,Warrensburg,NY 12885
y3] Name of Funeral Firm Making Disposition or to Whom
t= Remains are Shipped, If Other than Above
Address
'4
1U-
Permission is he eby granted to dispose of the human rains described a ove as indi ated.
aA Date Issued Registrar of Vital Statistics �,( (92A-P
sin ure)
District Number t:V�0 / Place 1-12 tee— g 79,
H. I certify that the remains of the decedent identified above were disposed of in accordance w' this permit on:
W Date of Disposition IJIb[,L Place of Disposition giii,,,r C am
2 (address)
W
Cl)
Ce (section) �j (lot number) (grave number)
QName of Sexton or Person in Charge of Premises `h� 6141
Z lease print)
W
SignatureCg g
Title
(over)
DOH-1555 (02/2004)