Burlett, William NEW YORK STATE DEPARTMENT OF HEALTH . -
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William J. Burlett Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 27,2011 1 52 War or Dates
1! Place of Death _ Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death n Natural Cause n Accident Homicide Suicide n Undetermined Pending
Circumstances Investigation
W' Medical Certifier Name Title
Joseph Mihindo,MD
Address
Murry St.Glens Falls NY
Death Certificate Filed ' District Number Register Number
City, Town or Village Glens Falls 5601 --i -7 9
❑Burial Date Cemetery or Crematory
❑Entombment August 30,2011 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
as n Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
I
ri Reinterment Date ; Cemetery Address
Registration Number
Re
Permit Issued to
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
b- Remains are Shipped, If Other than Above
aAddress
. 1
`13.
Permission is hereby granted to dispose of the human remainsj described above as indicated.
Date Issued 25 / 3 0 jiiRegistrar of Vital Statistics w '
signature)
District Number 5601 Place Glens Falls
•
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition '(built Place of Disposition Pt,,LL4 ,ww44-44ii.--
2 (address)
W
CO
O (section) lot number) (grave number)
Q• Name of Sexton or Perso in Charge of remises l�ny'r e r [Ant{
Z (please print)
Wilf-elLTitle Cl2�atAf aSignature
(over)
DOH-1555(02/2004)