Ponce, Santiago E. i,3 )
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Santiago E.Ponce Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/11/2020 45 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address 69 Bay Street#3,Glens Falls,New York 12801
• Manner of Death ❑ Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending
W C.) Circumstances Investigation
W Medical Certifier Name Title
0 Timothy Murphy Coroner
Address
52 HAVILAND AVE,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 473
▪Burial Date Cemetery,Crematory or Facility Name
10/19/2020 Pine View Crematory
Entombment Address
▪Cremation Queensbury Town,New York
Donation
Z Date Place Removed
Removal and/or Held
= and/or
Hold Address
0
d Date Point of
Cl) Li Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped,If Other than Above
Address
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/18/2020 Registrar of Vital Statistics Ro6ertnnefrew Curtis(E/ctranicallySignet
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1OI Ir1)zU Place of Disposition
(address)
W
re (section) (lot number) (grave number)
O• Name of Sexton or Person in Charge o Premises f�sgwtillp
(plea print)
W Signature Title (�"tir'ttifAL
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 014127 7
i
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#