Ernst Jr, Randolph f , t t7
NEW YORK STATE DEPARTMENT OF HEALTH ` �
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Randol h G. Ernst,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/25/2016 79 War or Dates n/a
'. Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause n Accident n Homicide Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Hayed Sidiori MD
Address
;. 100 Park Avenue,Glens Falls NY 12801
,:, Death Certificate Filed District Number Reg'st tuber
City, Town or Village�� Y 9 Glens Falls 5601
❑Burial Date Cemetery or Crematory
Entombment 09/27/2016 Pine View Crematory
Address
i Cremation Quaker Road, Queensbury, NY
Z Date Place Removed
0 Removal and/or Held
t`= and/or Address
(7) Hold
a
Date Point of
N n Transportation Shipment
G by Common Destination
_ Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
{ Permit Issued to Registration Number
VName of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
v 53 Quaker Road,Queensbury,NY 12804
.. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
1
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,. Date Issued /'�Z � ,�
( Registrar of Vital Statistics ( �-,� j1�y� (A)
r (signat re)
ij District Number 5 60( Place Glens Falls, ck)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 11 Nib, Place of Disposition ,u,Oth.) 10mtlorio-
W (address)
co
re
0 (section) 7l (lot number) (grave number)
pp Name of Sexton or Person in Charge of Premises `Arstp lai —J9444
'Z rplease print)
Signature £ 1 Title C'VEi iilie
(over)
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