Stevens, Gary 'II
-It -71/
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
:r; Name First Middle Last Sex
rjrr Gary Richard Stevens Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 13, 2014 76 War or Dates Vietnam
�•f' Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause (Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
;. Michael Adams MD
1
Address
1448 Route 9; Glens Falls,NY 12801
. Death Certificate Filed District Number Regise
>�r N tuber
'�
.. City, Town or Village Glens Falls 5601 ''� {
❑Burial Date Cemetery or Crematory
December 16, 2014 Pine View Crematory
❑Entombment Address
❑x Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
and/or Address
�' Hold
CO
0 Date Point of •
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
:; r Permit Issued to Registration Number
ti , Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
r•'; 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
iv; Remains are Shipped, If Other than Above
Address
▪ Permission is hereb granted to dispose of the humar`remains describe above as in•icate..
Date Issued j /!e. / Registrar of Vital Statistics el,�_ ,--) A n/f--
GEC \
(signature)
District Number 5601 Place Glens Falls
▪ I certify that the remains of the decedent identified above re disposed of
off in accordance with this permit on:
W Date of Disposition 1 Z iIL/11 Place of Disposition (It ,(L1 t� t?,.....
W (address)
U)
O (section) i(lot number) (grave number)
ei• Name of Sexton or Person 'n Charge of Premises to 1. J efitvil
'Z Tease print)
Si nature E� Title CO-owl-rat
9 t
(over)
DOH-1555(02/2004)