Granger, Herbert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Herbert John ranger Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/30/2015 63 years War or Dates
}- Place of Death Hospital, Institution or
Z City, T Kr WINK( Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
tJ Circumstances Investigation
O.
in Medical Certifier Name Title
Suzanne Bergin M D
AdgT?Main Street Warrensburg, NY 12885
iii Death Certificate Filed District Number Register Number
ii.'i!'ii City, TaigXr O&M Glens Falls 5601 54
M❑Burial Date . Cemetery or Crematory
02/02/2015 Pine View Crematorium
❑Entombment Address
13Cremation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2❑and/or
Address
U
Hold
O Date Point of
05 El Transportation Shipment
G! by Common Destination
iiiii Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date • Cemetery Address
giiil Permit Issued to Registration Number
Name of Funeral Home Barton- Mc Dermott Funeral Home, Inc. 00141
Address
9 Pine Street Chestertown, N Y 12817
Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
• Address
in. .
glE Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/02/2015 Registrar of Vital Statistics (Nct�,Y,r� W JvA�(s gnature)
Iii District Number 5601 Place Glens Falls Iv U
I I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 / � i�
III Date of Disposition Z/,3/3- Place of Disposition t'�,,0f—i (-ti„e4r,4-,
2 (address)
Lu
to
lr (section) /}, (lot number (grave number)
• Name of Sexton or Person in Charge of Premises (/ - �'^^
2. / (please print)
:,,,,„„,, Signature
G1 4. Title Ci'r...t(lr'r�
(over)
•
DOH-1555 (02/2004)