Townsend, Gary i 1 # 3(, L
NEW YORK STATE DEPARTMENT.OF HEALTH
Vital Records Section Burial - Transit Permit
. Name First Middle Last Sex
:PA Gary L. Townsend Male
rf Date of Death Age If Veteran of U.S. Armed Forces,
'r'rla9, 2016 57 War or Dates
e of Death Hospital, Institution or
Town or Village Glens Falls Street Address 173 Maple Street
er of Death X Natural Cause Accident I (Homicide Suicide Undetermined Pending
Circumstances Investigation
cal Certifier Name Title
r Robert Evans
.. Address
tie'Irongate,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number ,�//
City, Town or Village Glens Falls 5601 0'7(2
❑Burial Date Cemetery or Crematory
5/16/2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
co
0 Date Point of
u) Transportation Shipment
p 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
;tip Address
ti 53 Quaker Road, Queensbury, NY 12804
IName of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
;. .; Permission is hereby ranted to dispose of the human remains described abo e a d'cated.
ti Date Issued /l 20/6 Registrar of Vital Statistics "
(signature)
ti.. District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 5/17'/L Place of Disposition RncU,,. � -.
Ili Date
N
C
g
(section) ‘(lot nutiSti.) (grave number)
Name of Sexton or Person in Charge of remises ,., ,J
1Z j please print)
Signature Title rflekt1U/t
(over)
DOH-1555(02/2004)