Salzman, Ralph NEW YORK STATE DEPARTMENT OF HEALTH
3
6
Vital Records Section n ' Burial - Transit Per it
Name First Middle Last Sex
Ralph Salzman Male
Date of Death Age If Veteran of U.S. Armed Forces,
'° July 17,2011 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death n Natural Cause Accident ❑Homicide n Suicide ❑Undetermined Pending
imlli Circumstances Investigation
Medical Certifier Name Title
P. Christopher Hoy,MD
Address
Glens Falls,NY
:. Death Certificate Filed District Number Register Number
r :: City, Town or Village Glens Falls,NY 5601 •~�c
❑Burial Date Cemetery or Crematory
ill Entombment July 20, 2011 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury,NY 12801
Date Place Removed
Z Ti Removal and/or Held
2 and/or Address
H Hold
W
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
[7 Disinterment Date Cemetery Address
r]Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
ti!i. Remains are Shipped, If Other than Above
Address
• Permission is her by granted to dispose of the human r ains scribed t bove as i : -d.
Date Issued O'7 1c (( Registrar of Vital Statistics 2_ ,:17- . Gf
(signature)
)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
Z i '
ILI Date of Disposition .7 hi ht. Place of Disposition ,ntU' i,J Cnewejariun..
W (address)
N tY (section) /� (lot nu r) (grave number)
pName of Sexton or Per ;in Charge o Premises C ht,�t r ,,-t
Z ` (please print)
IliSignature L. Title ('lt a rn 4 tY(
(over)
DOH-1555(02/2004)