Fordrung, George NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George A. Fordrung Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 24, 2012 56 War or Dates
k Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address 9 Sherman Avenue Apt 4
Ali Manner of Death Natural Cause 1 I Accident I I Homicide Suicide Undetermined Pending
til Circumstances Investigation
w Medical Certifier Name Title
O. 11 tic^ �w�
Address 2 oc. S Ail
(Zl of
Death Certificate Filed District Numb Regi r er
City, Town or Village Glens Falls 5601 ''
❑Burial Date Cemetery or Crematory
November 27, 2012 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F" Hold
N
O Date Point of
u) Transportation Shipment
p by Common Destination
Carrier
n 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
:tT Remains are Shipped, If Other than Above
Address
W
.• Permission is her by granted to dispose of the human remains de cribed above a ' ated.
Date Issued / 027 aOIL Registrar of Vital Statistics '
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z / /�
W Date of Disposition /1 c4-, . Place of Disposition J'ft/kk1.'it-/ address
W )
co
re (section) ��9 f�num er) (grave number)
pName of Sexton Person i arge of Premises . J �j'C ao-1,,qr d
'Z (please print)
Signature Title a‘,44.13 L.- As
(over)
DOH-1555(02/2004)