Kanaly, Jr. William NEW YORK STATE DEPARTMENT OF HEALTH w It `i
Vital Records Section e - ? Burial - Transit Permit
Name First Middle Last Sex
William J. Kanaly,Jr. Male
X Date of Death Age If Veteran of U.S, Armed Forces,
June 3, 2012 56 War or Dates
=a. Place of Death Hospital, InstitutiOn'or
City, Town or Village Glens Falls Street Address 'Glens Falls Hospital
LU
p, Manner of Death X Natural Cause Accident Homicide n Suicide n Undetermined Pending
U ' Circumstances Investigation
W Medical Certifier Name Title
P.' Sean Bain MD
Address
100 Park Street Glens Falls NY 12801
' Death Certificate Filed District Number Register Number
e City, Town or Village Glens Falls 5601 dUZ
❑Burial Date Cemetery or Crematory
❑Entombment June 5,2012 Pine View Crematorium
Address
CI Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
O Date Point of
yTransportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment—
Date Cemetery Address
:a 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
I Remains are Shipped, If Other than Above
2 Address
Cer
U.F.
Permission is hereby granted to dispose of the human remains de
cribe ab e a 'cated.
Date Issued 06 5AO/ Registrar of Vital Statistics �
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition (,!%j,1 Place of Disposition pr"vu,..► ciovet-formbh
W (address)
co
re
(section) (lot number) r (grave number)
Q• Name of Sexton or Person in Charge of Premises a
rot r- -. (Matt
Z (please print)
W Signature „ frill, , i ><
Title Cti Nt1.c6L
r
(over)
DOH-1555(02/2004)