Emerson, Ralph ft-
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
Ralph W. Emerson Male
Date of Death Age If Veteran of U.S. Armed Forces,
• July 18,2012 83 War or Dates
F Place of Death Hospital, Institution or
• City, Town or Village Glens Falls Street Address Glens Falls Hospital
0' Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
' Circumstances Investigation
CI
1w Medical Certifier Name Title
Q. Mathew Varughese MD
Address
• 100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 3 4-f 2.
❑Burial Date Cemetery or Crematory
July 24, 2012 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date 1 Place Removed
Z I !Removal and/or Held
O and/or Address
H Hold
CO
O Date Point of
NI I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
;L Remains are Shipped, If Other than Above
Address
Au
IN
• Permission is hereby granted to dispose of the human remains described above as ind)cated.
•
Date Issued 71 20/ i Z, Registrar of Vital Statistics W -a
(signature)
District Number 5601 Place Glens Falls i'`-'4 . (? 10
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1-21-it Place of Disposition 1:r4U1n.1 C 4u t'' .
2 (address)
W
CO
O (section) /11 (lot number) r (grave number)
pp• Name of Sexton or Person in Charge of P emises 1 hrt)fpLt/ „1
'Z _f (please print)
Signature A-t pL Title CRw=M/}�p/l
y (over)
DOH-1555(02/2004)