Ladd Sr, Daniel NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
p' Name First Middle Last Sex
"` Daniel Charles Ladd,Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
rOS August 3,2015 63 War or Dates _
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 15 Natural Cause n Accident I 1 Homicide n Suicide ri Undetermined Pending
Circumstances Investigation
Medical Certifier Name 1` O. Titler 'CI. 71 C lea vexm ID
Address 1 0 D PC��I J t� &)( f'1 J FCi If
i N 1 3Yo 1
Death Certificate Filed District Number Register�JVer
yr City, Town or Village ��
❑Burial Date Cemetery or Crematory
❑Entombment August 10, 2015 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z El Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
E.Transportation Shipment
p by Common Destination
Carrier
El
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
,f„s-
V Permit Issued to Registration Number
`
,� Name of Funeral Home Regan Denny Stafford Funeral Home 01443
;
fyX
Address
53 Quaker Road, Queensbury,NY 12804
• Name of Funeral Firm Making Disposition or to Whom _
Remains are Shipped, If Other than Above
Address
',r Permission is hereby ranted to dispose of the human remains des i ed abo as ' i ted.
'
Date Issued �b� ?� Registrar of Vital Statistics
%f (signature)
; f
s; District Number j'/ Place as/PS lift6 ,/`S ia�J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�Z g era l,,._,
Date of Disposition 4�101�6 Place of Disposition �',,,1
W (address)
0 (section) lfot numt (grave number)
Z Name of Sexton or Person in Charge of Premises 6 "` a„4(
(please print)
W Signature Title Az60/ifeet
(over)
DOH-1555(02/2004)