Molner, Joseph NEW YORK STATE DEPARTMENT OF HEALTH i / 5 L
Vital Records Section Burial - Transit Permit
- f Name First Middle Last Sex
Joseph W. Molner Male
r Date of Death Age If Veteran of U.S. Armed Forces,
January 24, 2015 86 War or Dates
}.. Place of Death Hospital, Institution or
-Z City, Town or Village Queensbury Street Address 13 Stevens Road
10
Manner of Death X Natural Cause n Accident ❑Homicide E Suicide Undetermined Pending
t —Circumstances Investigation
i Medical Certifier Name Title
Danushan Sorriabalan MD
Address
1 9 Carey Road,Queensbury,NY 12804
Death Certificate Filed District Number Regjster Number
City, Town or Village Queensbury,NY 5657 `�
❑Burial Date Cemetery or Crematory
1/27/2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
E Hold
N
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
n1 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
1 Remains are Shipped, If Other than Above
Address
.14 14
Permission is hereby granted to dispose of the human emains described above as indicated.
Date Issued I [ 2'-7 I I < Registrar of Vital Statistics a -ti_
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition t/i/is- Place of Disposition „(0,K,/ ( . 0r44,_.,
2 (address)
W
CO
W (section) (lot numbs _ (grave number)
pName of Sexton or Person in Charge of Premises G�+<, a..
Z J (please print)
W Signature A 14..E Title t ixfi
(over)
DOH-1555(02/2004)