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DeLong, Chris NEW YORK STATE DEPARTMENT OF HEALTH toms4 37 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Chris J DeLong i Male '. Date of Death Age i If Veteran of U.S. Armed Forces, July 29, 2012 64 War or Dates Place of Death Hospital, Institution or Z City, Town or Village Moreau Street Address Glens Falls Hospital tit Manner of Death n Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation w Medical Certifier Name Title gi William Tedesco MD Address 3 Irongate Center,Glens Falls,NY 12801 Death Certificate Filed District Number Registey Nmber City, Town or Village Glens Falls 5601 ��j ❑Burial Date Cemetery or Crematory ❑Entombment July 31, 2012 Pine View Crematorium Address ©Cremation 21 Quaker Road, Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold N 0 Date Point of O. N 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 II+- Remains are Shipped, If Other than Above 2 Address l ,lii Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 7/7//l2 Registrar of Vital Statistics L)cM14---,s, U� (signature��J) District Number 5601 Place Glens Falls ) 1, l Li 9 b t 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- I-it Place of Disposition P(.&Uliw Cn„ !isri ., 2 (address) W U) re 0 (section) ,(lot number) (grave number) p Name of Sexton or Person in Charge of Premises 7(,1}gr�r 3 ,� Z (((please print) W IIL. . Signature Title C enni+t. (over) DOH-1555(02/2004)