Curley, Jeffrey C.Va
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
p Name First Middle Last Sex
Jeffrey David Curley Male
Date of Death Age If Veteran of U.S. Armed Forces,
• December 17, 2016 59 War or Dates NA
Place of Death Hospital, Institution or
City, Town or Village Town of Queensbury Street Address 214 Burke Drive Apt#A Queensbury, NY
Manner of Death n Natural Cause ❑Accident ❑Homicide n Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Sildrica MD
Address
Tim Murphy Coroner 52 Haviland Ave Glens Falls,NY
Death Certificate Filed Dispct Nu ber egister.Number
City, Town or Village Town of Queensbury,NY (.0 c c
❑Burial Date Cemetery or Crematory
December 20, 2016 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
F Hold
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0 Date Point of
yI I Transportation Shipment
a by Common Destination
Carrier
l i Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
`' Permit Issued to Registration Number
: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
0 53 Quaker Road, Queensbury, NY 12804
'`'' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
0Permission
is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 13 1 3c,1 l(o Registrar of Vital Statistics M-ris--__ . ar��_9____,
1 ` (signature)
' District Number Place / L�� O � ��,
,.:.,,,,
I certify that the remains of the decedent identified above were disposed of in accordan i this permit on:
7
W Date of Disposition Wail Place of Disposition ,U,u.,� C ` --
2 (address)
W
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re (section) (lot numb ) (grave number)
QName of Sexton or Person in Charge of Premises f/t,i y j0"/100-
Z ( lease print)
w Title �t1 WL Signature G �}
(over)
DOH-1555(02/2004)