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Westcott, Timothy
it 53 8 NEW YORK STATE DEPARTMENT OF HEALTH' Vital Records Section Burial - Transit Permit Name First Middle Last • Sex Timothy Westcott male Date of Death Age If Veteran of U.S. Armed Forces, n/a 1 0/1 0/2 01 2 61 War or Dates 1 Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls iallManner of Death n Natural Cause 0 Accident D Homicide D Suicide D Undetermined D Pending tki Circumstances Investigation tu Medical Certifier Name Title 0 Darci Grubbs MD Address 102 Park Street Glens Fallsil NY Rior , GlensFalls Death Certificate Filed Distrigt i�nber Register N der City, Town or Village _ 7 a( El Burial Date Cemetery or Crematory 1 0/1 2/201 2 Pine View Crematory DEntombment Address ®Cremation Quaker Rd. Queensbury . qii Date Place Removed t❑Removal and/or Held fl and/or Address M= Hold to 0 Date Point of i0 Transportation Shipment as by Common Destination Carrier „j D Disinterment Date Cemetery Address Date Cemetery Address DReintermentali Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford 01 4 4 3 igili Address 53 Quaker Rd. Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom ,. Remains are Shipped, If Other than Above a Address at . Permission is hereby granted to dispose of the human remains descri `ed above,as in • ted. Rill © 201 2-- Registrar of Vital Statistics 1-#. G��"�" Date Issued /�� 9 (signature) District Number SO/ Place ‘/,e?,,,0 /29/X, Ity p j® certify that the remains of the decedent identified above were disposed of in accordance with this permit on: tit Date of Disposition 001I5 lit Place of Disposition at Uff W ( ri✓� (address) EU flt 0 (section) A,. (lot number) y- (gravenumber) Name of Sexton or Person in Charge o Premises r°"� ((please print) IA °ILSignature Title Mat-d (over) DOH-1555 (02/2004)