Choppy, James NEW YORK STATE DEPARTMENT OF HEALTH ti iIyL
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
James E. Choppy I Male
Date of Death Age I If Veteran of U.S. Armed Forces,
September 8, 2011 60 I War or Dates
k. Place of Death Hospital, Institution or
Z, City, Town or Village Glens Falls j Street Address Glens Falls Hospital
es; Manner of Death X Natural Cause I 'Accident Homicide Suicide Undetermined Pending
tii
u1 Circumstances - Investigation
I Medical Certifier Name Title
Dean Reali MD
11
Address
100 Park Street Glens Falls,NY 12801
Death Certificate Filed ' District Number ' Register Number ^�
a1 City, Town or Village Glens Falls 5601 I L1O —
❑Burial Date Cemetery or Crematory
❑Entombment September 13, 2011 Pine View Crematorium
Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal
j and/or Held
and/or
I' Hold Address
W
O Date Point of
NI I Transportation I Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment
Date Cemetery Address
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
X Address
W:
lit
Permission is hereby granted to dispose of the human remains describes a ov s i ted.
.y A�i�c/ d v�
Date Issued Qfc�y�. a// Registrar of Vital Statistics
(signature)
. District Number 5601 Place Glens Falls /�/ lo22/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
•
W Date of Disposition o(lab Place of Disposition _ -P�,c,V tto Crr•..t f.r!vv..W (address)
co
GAName of Sexton or Per n in Char a g of Premises c k ,►(section) _ (lot number) (grave number)
AV
Z Tit
print)
Ill Signature Title (R(�N?}ZGUL
(over)
DOH-1555(02/2004)