Grey Sr, William t n
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
f7.07§ William G. Grey,Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
1:: December 9, 2015 63 War or Dates NA
Place of Death Hospital, Institution or
XXX Town)olillla •X Moreau
Street Address 129 Saratoga Ave. South Glens Falls,NY
Manner of Death Natural Cause ( 'Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Glen Anderson MD
Address
r 4161 Carey Rd. Queensbury, NY 12804
ADeath Certificate Filed District IIlbej Regis Number
r 00% Town A LIT Moreau �� ,
❑Burial Date Cemetery or Crematory
December 10, 2015 Pine View Crematorium
❑Entombment Address
1 Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z l I Removal and/or Held
9. and/or Address
H Hold
CD
O° Date Point of
%;[ I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
[ Reinterment Date Cemetery Address
Permit Issued to Registration Number
k Name of Funeral Home Regan Denny Funeral Home 01444
''' Address
r,... 94 Saratoga Avenue, South Glens Falls,NY 12803
r�j; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
,+'; Permission is hereby granted to dispose of the human remains desc ed above as indicated.
;,`� Date Issued ) /ioJi is Registrar of Vital Statisticsjaiq
"‹.:: (signature)
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District Number � Place (s
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition , Z.4 c/-,S- Place of Disposition 2,,-,e 0 raw 6 re.„,74.
2 (address)
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O (section) `` (lot number) (grave number)
p Name of Sexton o Perso in Charge of Premises -,Jr,.-jia.rt ‘4- c- €
Z (please print)
LU Signature / A Title 4-re.,,z 4, A .S4.H.74
(over)
DOH-1555(02/2004)