Combs, Jeffrey 4 !((
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jeffrey G. Combs Male
air Date of Death Age If Veteran of U.S. Armed Forces,
November 3, 2011 57 War or Dates
ZPlace of Death Hospital, Institution or
, City, Town or Village Moreau Street Address 1640 Route 9
Manner of Death X Natural Cause Accident n Homicide Suicide Undetermined Pending
U3 Circumstances Investigation
Medical Certifier Name Title
P. Darci Gaiotti-Grubs,MD
Address
Glens Falls,NY
i. Death Certificate Filed District Number Register Number
City, Town or Village Town of Moreau,NY
❑Burial Date Cemetery or Crematory
November 7, 2011 Pine View Crematory
❑Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
y Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
!' y1 Permit Issued to Registration Number
::: 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
g Address
rd
b3j
Permission is hereby granted to dispose of the human rema'ns described abo e as indicated.
Date Issued //-4/:'D// Registrar of Vital Statistics ivao_.tic_ 9,- f )
(signature)
: District Number ,S(54 Z' Place Town of Moreau,NY
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 ti I N Place of Disposition 2v4 UL J CPO a r i 4.►.
2 (address)
W
CC
CL (section) (lot numb (grave number)
pName of Sexton or Person in Charge of Premises A,s-Ivi.er Jt44
W g fC (please print)
Signature Title 12 M1g"ttr(L
[ (over)
DOH-1555(02/2004)