Grogan, Christopher NEW YORK STATE DEPARTMENT OF HEALTH 4 (Ai
Vital Records Section Burial - Transit Permit
ai Name First Middle Last Sex
Christopher Shane Grogan Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/28/2011 32 years War or Dates No
Place of Death Hospital, Institution or
§� ffown or loam Wilton Street Address 776 Saratoga Road
Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide I—I❑Undetermined ❑Pending
Ut Circumstances Investigation
la Medical Certifier Name Title
P. John Demartino Coroner
Address
339 Northline Rd. Ballston Spa, Ny
MI Death Certificate Filed District Number Register Number
Wirown or AUX( Wilton 4569 31
0Burial Date Cemetery or Crematory
❑Entombment 10/03/2011 Pine Creamatorium
gi Address
Ii[,Cremation Queensbury
Date Place Removed
Kri❑Removal and/or Held
and/or Address
h_ Hold
0.
0 Date Point of
IL i—i
0 Li Transportation Shipment
C5 by Common Destination
Rii Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
in Name of Funeral Home Mb Kilmer Funeral 01079
Rili Address
82 Broadway Fort Edward, Ny 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'. Address
ILI
CL
>` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/03/2011 Registrar of Vital Statistics ll��Mi; i%�f Iesign
mi
iiIi District Number 4569 Place Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k �
l Date of Disposition to -S- (( Place of Disposition 1 i ne cl ew CUQw a'0 r iuvvl
(address)
Ui
W.
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises i "M o4 Et.„nelle
2 — (please print)
Signature Title CC-ewna.4 4sci •
(over)
DOH-1555 (02/2004)