Misner, George # -71�
NEW YORK STATE DEPARTMENT OF HEALTH- 10'
Vital Records Section / Burial - Transit Permit
r Name First Middle Last Sex
4 George M. Misner Male
:f::
;fr Date of Death Age If Veteran of U.S. Armed Forces,
r1 April 4, 2015 88 War or Dates WWII
r Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 19 Sycamore Drive
Manner of Death X Natural Cause Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
r Paul Bachman,MD
1 Address
.0‹,,,Warrensburg,NY
:;-. Death Certificate Filed District Number Re i Number
*.e City, Town or Village Queensbury,NY 5657
El Burial Date Cemetery or Crematory
April 10, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z [ I Removal I and/or Held
O and/or Address
t Hold
Cl)
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
r r 53 Quaker Road, Queensbury, NY 12804
'. ga Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
d• Permission is hereby granted to dispose of the huma r ains described(�' ove as indicated.
Date Issued \ Q l c Registrar of Vital Statistics � - `-'\ ' 1--�-"....-
r.Y (signature)
:.rr:
: D: istrict Numb Fer 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition t4 1 ill Os- Place of Disposition j 4L t'-'
2 (address)
W
CO
rt (section) hot number) (grave number)
QName of Sexton or Person in Charge of Premises ,t `
W � 4..
(please print)
Signature Title rizti4
(over)
DOH-1555(02/2004)