Greenidge, Lloyd .rQ �
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Names, Finn d Middl Se
Y Fitzgerald � nidge hale
DitglQf eajh A If Veteran of U.S. Armed Forces,
years War or Dates
I— Place of Deathltyy Hospital, Institution or
Town.o Horicon 171 Clearwater Lake Road
K , Street Address
ILIa Manner.of_Death
Natural Cause ❑Accident 0 Homicide 0 Suicide 0.Undetermined._ ..Pending
W Circumstances Investigation
W Medical•Certifier Name Title
4 Ageel A. Gillani Md, Facp
irk St, Pruyn Pavilion, Glens Falls, Ny 12801_
I
.th CertificFiled District Number Register Number
• X g1`.,.Town c Horicon • - 5654 1
[]Burial Date Cemetery or Crematory
05/18/2015 Pine Vew Crematorium
❑Entombment Addr ss .
;Cremation Queensbury, NY
Date Place Removed
Z❑Removal and/or Held
2 and/or, Address
IA▪ Hold
0 Date Point of
a` Transportation Shipment
L' by Common Destination
-Carrier
�Disinterment
Date Cemetery Address'
Q Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton Mcdermott Funeral Home 010134
Addrls1§ine St, Chestertown, NY 12817
,, NameofFuneral Firm Making_Dispositionor to Whom
Remains are Shipped, If Other than Above
Address
C1 . Permission is hereby granted to dispose of the human remains escribed above indicat
Date Issued 05/13/2015 Registrar of Vital Statistics .�
(signature)
District Number5654 Place Horicon
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
W Date of Disposition b I hj1l( Place of Disposition %E.'11L. L r
W (addres§)
U,
IX (section) (lot number)sivire (grave number)
• Name of Sexton or Person inCharge o Premises �,
Z (pl ase print)
Ili
Signature Title fllPi- itt?1,
(over)
DOH-1555 (02/2004)