Geroux, Doandl NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald Lawrence Geroux Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 9, 2015 77 War or Dates n/a
l'%:% Place of Death Hospital, Institution or
City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
ii Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
tg Medical Certifier_ Name Title
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Death Certificate Filed ` District Number Register N mp�r.-
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City, Town or Village Glens Falls, NY 5601 7 /
❑Burial Date Cemetery or Crematory
June 12, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
N
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
▪ Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
• Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i
Permission is hereby granted to dispose of the human r ains de cribed a ove as indicated.
Date Issued QI<i) j( 4:20/5* Registrar of Vital Statistics -J2 I 40
(signature)
District Number 56,c/ Place IC-
-211" ) L7-7
I certify that the remains of the decedent identified above were disposed of in accor nce with this permit on:
Z
W Date of Disposition (D Ia.- 1t Place of Disposition „lQ u -eW C.f-Om g4c.r
2 (address)
W
co
ce
(section) (lot number) (grave number)
pName of Sexton or Person in Char of Premises — 5 o4-1‘y vne/1e
Z /.. // / (please print)
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Signature ..v.�v//j Title
(over)
DOH-1555(02/2004)