Hurlburt, Sherman NEW YORK STATE DEPARTMENT OF HEALTH -Vital Records Section Burial - Transit Permit
•.. Name First Middle Last Sex
Sherman D. Hurlburt Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 25, 2016 65 War or Dates
Place of Death Hospital, Institution or
• City, Town or Village Kingsbury Street Address 700 County Rt. 41
es Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
a Medical Certifier Name Title
M. Glen Anderson
Address
161 Carey Road,Queensbury,NY 12804
v▪ e Death Certificate Filed District Number Register Number
▪ City, Town or Village Kingsbury 5762 ,j
❑Burial Date Cemetery or Crematory
August 26, 2016 Pine View Crematory
❑Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
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O Date Point of
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Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
-f;: Name of Funeral Firm Making Disposition or to Whom
:+ Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /,71 // Registrar of Vital Statistics aruL.A.,_
(signature)
'▪" District Number 5762 Place Kingsbury
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition g/r�:[i, Place of Disposition r•� v,,,/
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p Name of Sexton or Person.in Charge of Premises Rr Irk, M
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Signature 4Title A{
(over)
DOH-1555(02/2004)