Creath Jr, Marion NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transiclf
t ermit
rrr: Name First Middle Last Sex
Marion Glenn Creath,Jr. Male
ti::: Date of Death Age If Veteran of U.S. Armed Forces,
rx'ti March 15, 2015 82 War or Dates
k
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 24 North Church Lane
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
0
Medical Certifier Name Title
John Sawyer DR.
: rr Address
g 14 Manor Drive,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
i:::* City, Town or Village Queensbury 5637
... ❑Burial Date Cemetery or Crematory
March 17, 2015 Pine View Crematory
❑Entombment Address
EI Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
H Hold
N
O Date Point of
O.
• Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
rrr, Permit Issued to Registration Number
s;::r: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
;4: 53 Quaker Road, Queensbury,NY 12804
.ti
c; 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 emains described above as indicated.
31 h--t bock Ct . ram-_
'•ti�• Date Issued Re istrar of Vital Statistics Cv�a.—�
'L:�
'rr: (signature)
District Number 5637 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z W Date of Disposition 3- I q P,- ►s Place of Disposition � �
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W (address)
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O (section) r� (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises t •„h 0�Y 1.7r,j np 11e
Z (please print)
W Signature (&,,,,,,iL Title Cr.e,r►c,.- i,.y i d
(over)
DOH-1555(02/2004)