Everett, William # z 9(1
NEW YORK STATE DEPARTMENT OF HEALTH Pi
Vital Records Section Burial - Transit Permit
✓ Name First Middle Last Sex William J. Everett Male
Date of Death Age If Veteran of U.S. Armed Forces,
'r▪ A• pril 6, 2016 86 War or Dates
IPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
M• anner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier 1Name Title
.r,. Marvin Davidowitz M.D.
"'f
'rr:6 Address
.:: 100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Regist Number
:;Se City, Town or Village s 1�/ Y
❑Burial Date Cemetery or Crematory
April ls, 2016 Pine View Crematorium
Ill Entombment Address
E1 Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
Cl)
0` Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
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Reinterment Date Cemetery Address
'rr Permit Issued to Registration Number
'; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
:;.;:: Address
53 Quaker Road,Queensbury +,NY 12804
... Name of Funeral Firm Making Disposition or to Whom
ib+' Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as ind' t d.
.% Date Issued 0(7/ 1/2.01� Registrar of Vital Statistics
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N f District Number 6Z O( Place �/, /AA /177
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition '9-19-/(p Place of Disposition jD 7 g_0 i Gi.ci C/8444e�'a,�/
2 (address) /
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pCC (section) f of number) (grave number)
Name of Sexton or P r i Charge of Premises J(,,/, �, inet& i.,t.
Z W (p/ease print) ,
Signature Title G,112-'1'74-�o r
(over)
DOH-1555(02/2004)