Combs, Ronald NEW YORK STATE DEPARTMENT OF HEALTH A- (17
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ronald C. Combs Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 8, 2012 59 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Luzerne Street Address 85 East River Drive
Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined {—Pending
Circumstances Investigation
Medical Certifier Name Title
Dr Gillani,MD
Address
Glens Falls,NY
.: Death Certificate Filed District Number Register Number
``a City, Town or Village Lake Luzerne,NY
❑Burial Date Cemetery or Crematory
September 12, 2012 Pine View Crematory
❑Entombment Address
LI Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z 1-1 Removal and/or Held
2 and/or Address
H Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
':1 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
Remains are Shipped, If Other than Above
Address
e
e
Permission is hereby granted to dispose of the huma re ains des ibed ab ve/as indicated.
Date IssuedcY-//-{26/2 Registrar of Vital Statistics -
(signature)
District Number SZ Place Lake Luzerne,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition °\-I1-IZ Place of Disposition Ft*Oti,‘,) ,-i„'tarit--
2 (address)
W
rt (section) /lJ t (lot numbe� ,1 (grave number)
pName of Sexton or Person in Charg of Premises C h►�I F��l
Z (please print)
ui
Signature (1 Title Cil,tdQi
(over)
DOH-1555(02/2004)