Whitehead, Henry } ft.6Z.
Vital Records Section
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
r;:; Name First Middle Last Sex
r :: Henry Travis Whitehead Male
Date of Death Age If Veteran of U.S. Armed Forces,
;:. February 5, 2015 86 War or Dates Navy
�;1
kPlace of Death Hospital, Institution or
City, Town or Village Moreau Street Address 198 Bluebird Road 1rManner of Death X Natural Cause Accident I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
;; John A. Sawyer,MD
:'Y
Address
rr 9 Carey Road,Queensbury,NY 1280''
jf: Death Certificate Filed District Number Register Number
.•: City, Town or Village More' _
❑Burial Date Cemetery or Crematory
February 9, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, N 14
Date i ice Removed
Z Removal ( and/or Held
and/or Address
H Hold
th
O Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
";fr Address
53 Quaker Road, Queensbury, NY 12804
':: Name of Funeral Firm Making Disposition or to Whom
Ir'.' Remains are Shipped, If Other than Above
Address
'ti
Permission is hereby granted to dispose of the human rem ' s descr e above as indicated.
1. Date Issued (94(2 W Registrar of Vital Statistics C7(sIgnature)
District Numberc7pD-- Place Moreau,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition zholic Place of Disposition wolf.......,-- L'.,.) r-
2 (address)
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N
tY (section) (lot nu r) (grave number)
Q il Name of Sexton or Person in Charge of Premises (L 3vv.Ai
Z Ir.,
(please print)
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SignatureTitle (TSev 674
(over)
DOH-1555(02/2004)