Graves Sr, James II
NEW YORK STATE DEPARTMENT OF HEALTH �''
Vital Records Section Burial - Transit Permit
K. Name First Middle Last Sex
rj;:, James Robert Graves,Sr. Male
Oin Date of Death Age If Veteran of U.S. Armed Forces,
September 24,2015 66 War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
jg Manner of Death I XI Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
:51 Scott Biasetti,MD
rrf Address
N 100 Park Street,Glens Falls,NY 12801
?' Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 ((�� 3
❑Burial Date Cemetery or Crematory
El Entombment September 28,2015 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
2Z Removal and/or Held
and/or Address
t Hold
CO
d Date Point of
N. Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
r.r Permit Issued to Registration Number
:: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
'rr
Address
53 Quaker Road, Queensbury,NY 12804 _
r:: 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 described above as indicated.
'; .
..�^r Date Issued 9 /zg/S Registrar of Vital Statistics W
. (si ature)
District Number os▪; .5 bQ) Place 6 (QMS Vo,\\S �)\)
t- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Disposition9 3 Place of Dispositionf ,ng V;e i,J A W Date of � a�� �' �/'2irl� Di'i icIrr
W (address)
CO
C (section) (lot number) (grave number)
pName of Sexton or Per on in Charge of Premises .,,.,i �,, �4.,,.razzive
Z (please print)
ILI
Signature Title GIG4-44.7c,- �1
(over)
DOH-1555(02/2004)