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Hans, Sr. Theodore
4 . IL itIZZ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit :,' Name First Middle Last Sex Theodore M. Hans, Sr. Male Date of Death Age If Veteran of U.S. Armed Forces, March 5, 2011 85 War or Dates World War II :14 Place of Death Hospital, Institution or :Z City, Town or Village Queensbury Street Address 5 Duncan Cove Rd. 0, Manner of Death X Natural Cause ' Accident I I Homicide Suicide Undetermined Pending Circumstances Investigation us Medical Certifier Name Title P Robert Reeves Dr. Address 3 Irongate Center,Glens Falls,NY 12801 Death Certificate Filed District Number Regi er Number i . City, Town or Village Queensbury 5657 1 ❑Burial Date Cemetery or Crematory ❑Entombment March 7,2011 i Pine View Crematorium Address ©Cremation Quaker Road, Queensbury,NY 12804 Date Place Removed Z I I Removal , and/or Held and/or Address H Hold N 0 Date Point of N I I Transportation Shipment aby Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date 1 Cemetery Address Permit Issued to Registration Number Name of Funeral Home Sullivan Minahan & Potter j 01675 Address 407 Bay Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom M Remains are Shipped, If Other than Above XAddress W Permission is hereby granted to dispose of the human reins described above as indicated. Date Issued Z� Ic 0Registrar of Vital Statistics CI . )IC.L....__ (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 r� iuDate of Disposition $-11-it Place of Disposition 7 ,ntOw-) CIi'^si 4r,6r` 2 (address) N pCt (section) (lot nu er) (grave number) Name of Sexton or P rson in Char a of Premises t b r.stG a4 me Z (please print) W Signature Title CSC-mh i0a, (over) DOH-1555(02/2004)