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Fordrung, Adrian
IT tt NEW YORK STATE DEPARTMENT OF HEALTH �� Burial - Transit Permit Vital Records Section A Name First Middle Last Sex Adrian Fordrung Male Date of Death Age If Veteran of U.S. Armed Forces, :. October 31, 2011 54 War or Dates -`.' Place of Death Hospital, Institution or City, Town or Village Queensbury Street Address 28 Indiana Ave tz Manner of Death X Natural Cause I I Accident I I Homicide piSuicide n Undetermined Pending Circumstances Investigation Medical Certifier Name Title cl �b 3gL,-c L6 V ti Itt.t i • Address Death Certificate Filed District Number Rcgist�Number as City, Town or Village Town of Queensbury 5657 ❑Burial Date Cemetery or Crematory ❑Entombment November 2, 2011 Pine View Crematorium Address ©Cremation 21 Quaker Road, Queensbury,NY 12804 Date Place Removed Z I I Removal and/or Held O and/or Address F" Hold N 0 Date Point of N n Transportation Shipment p by Common Destination Carrier n Disinterment Date Cemetery Address Reinterment Date Cemetery Address ,^n Permit Issued to Registration Number a: Name of Funeral Home Regan & Denny Funeral Home 01443 Address 53 Quaker Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom , : Remains are Shipped, If Other than Above .X, Address .iG VS Permission is hereby granted to dispose of the human re ains described ab ye as indicated. Date Issued -� i Registrar of Vital Statistics Xiv► Cf• (signature) District Number 5657 Place Town of 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 it 131 it Place of Disposition Ft..U,tv, r„/0.#{01 Iv,W (address) co re (section) (lot numb ) (grave number) Z Name of Sexton or Person ' Charge of Premises t,s+ r ra�tN W (please print) Signature7 9 �/- Title CQ�mq,o'.( 41.•—.. (over) DOH-1555(02/2004)