Gregory, Hugo i i_
if-7‘03
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
x..• Name First Middle Last Sex
Hugo R. Gregory Male
▪ Date of Death Age If Veteran of U.S. Armed Forces,
December 7, 2014 92 War or Dates
'''iPlace of Death Hospital, Institution or
City, Town or Village Village Street Address 71 Boulevard
• Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
ti*I David Foote Dr
Address
Main Street,Hudson Falls,NY 12839 _
Death Certificate Filed District Number Register Number
.. City, Town or Village Hudson Falls 5726 r) /
❑Burial Date Cemetery or Crematory
CI Entombment December 9, 2014 Pine View Crematorium
Address
EI Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
N
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
ti : Name of Funeral Home Regan Denny Stafford Funeral Home 01443
▪ Address
••j`' 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
gi
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /d-//t►/? p/V Registrar of Vital Statistics &fra... < &. 6. ` -_ ,
(signature)
District Number Place
5726 Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accord nce with this permit on:
w Date of Disposition ,2'ldT',4lace of Disposition Ave-- V/�' �j�r1.�
W ( ress)
N
CL (section) 564 (lot nuymber) (grave number)
p0 Name of Sexto r Per ' Charge of Premises /o.J /Y�'►
'Z (please 7:6L__ igs...71
Signatur ! CI Title
(over)
DOH-1555(02/2004)