Ryerson, William NEW YORK STATE DEPARTMENT OF HEALTH • 1 -V.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William F' Ryprson Male
Date of Death Age If Veteran of U.S. Armed Forces,
` ` Ji , ? -1 86 yrs_ War or Dates WWII/ Korean Conflict
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death 0 Natural Cause El Accident El Homicide 0 Suicide Undetermined Pending
itiCircumstances Investigation
tu Medical Certifier Name Title
Dean Reali MD.
Address
' 00 Park St- _ , ( 1Pnc Falls NY_ 17801
': Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 260
OBurial Date Cemetery or Crematory
OEnfombment June 06, 2011 PineView Crematorium
Address
OCremation Queensbury, NY. 12804
Date Place Removed
gEl Removal and/or Held
and/or Address
"` Hold
0 Date Point of
Transportation Shipment
C by Common Destination
Carrier
lE
El Disinterment Date Cemetery Address i'l
>``[�Reinterment Date Cemetery Address
iiihp Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 011 36
Address
18 George St - , Fort Ann, NY_ 17877
giiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
;
fa
Permission is hereby granted to dispose of the human remains de r'bed abo e as' icated.
Date Issued June 06, 2 01 Registrar of Vital Statistics .�� i �;.
(signature)
<< District Number 5601 Place City of Glens Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordancec with this permit on:
Place of Disposition t At Vat.) (,
liri� Date of Disposition to���i� p '� U' rtiY6C{OM/ti
(address)
lire
tlf
Cr (section) (lot numbe (grave number)
Name of Sexton or Perso in Charge of emises t)s t -titan
2 7 please print)
Signature Title c AhV*
(over)
DOH-1555 (02/2004)