Tirado, Juan NEW YORK STATE DEPARTMENT OF HEALTH4 Vital Records Section Burial - Transit Permit
Sa Name First Middle Last Sex
>` i Juan Tirado Male
Date of Death Age If Veteran of U. rmed Forces,
< { October 23,2016 90 War or Dates
r Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 12 Fairway Ct.
Manner of Death 1 Natural Cause 0 Accident Homicide 1 1 Suicide I I Undetermined n Pending
1 Circumstances Investigation
la 1. Medical Certifier Name Title
irk Patricia Auer,NP
] Address
161 Carey Road,Queensbury,NY 12804
q. Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657
❑Burial Date Cemetery or Crematory
❑Entombment October 25, 2016 Pine View Crematory
Address
ED Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z 1-7 Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
5 ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
ri Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
v 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
IAddress
if
Permission is-hereby granted to dispose of the human r m ins described abov as indicated.
::... � G,
�� Date Issued � ��o\�-(Ic�U((p Registrar of Vital Statistics
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition /o)2Sf i(, Place of Disposition gra ,,,,d ( i c, L.
(address)
W
N
pCC (section) (lot numbe (grave number)
Name of Sexton or Person in Charge of Premises A,t5 Giilir
Wplease print)
Signature LTitle (lPie Yh►1714—
(over)
DOH-1555(02/2004)