Hearn, Garry NEW YORK STATE DEPARTMENT OF HEALTH 'MI
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Garry Jack Hearn Male
:n Date of Death Age If Veteran of U.S. Armed Forces,
June 20,2011 53 War or Dates
°: Place of Death Hospital, Institution or
-: City, Town or Village Queensbury Street Address 13 Belle Ave.
ct Manner of Death n Natural Cause , 'Accident Homicide E Suicide Undetermined x Pending
Circumstances Investigation
Medical Certifier Name Title
3 Gary Scidmore Coroner
Address
Warren County Municipal Center,Lake George NY
Death Certificate Filed District Nu ber Re ister Number
City, Town or Village Queensbury �` n
9
❑Burial Date Cemetery or Crematory
Entombment June 23,2011 Pine View Crematorium
Address
0 Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
t: Hold
co
0 Date Point of
N n Transportation Shipment
p by Common Destination
Carrier
E Disinterment Date Cemetery Address
[—Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01464
Address
53 Quaker Road, Queensbury,NY 12804
yr Name of Funeral Firm Making Disposition or to Whom
tk,' Remains are Shipped, If Other than Above
Address
at
Permission is hereby granted to dispose of the human remains described move as indicated.
Date Issued ( r,l z )Q01 ) Registrar of Vital Statistics " ___. q, tsojn_, -�
(signature)
' District Number (.p Cf Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Date of Disposition LM hi Place of Disposition Pntt1icv, Cc<tort,,,_
Ill
2 (address)
N
CC
(section) (Irnumber) (grave number)
Z Name of Sexton or Person in Charge %f Premises 1,�} r t or
�,, ���� + (please print)
Signature L Title Cn.in t OIL
(over)
DOH-1555(02/2004)