French, Carl NEW YORK STATE DEPARTMENT OF HEALTH it
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
`A:: Carl French Male
.K: Date of Death Age If Veteran of U.S. Armed Forces,
°r March 11, 2014 96 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls, Street Address The Pines At Glens Falls
Manner of Death 'X Natural Cause I 'Accident [ 'Homicide l_ Suicide I I Undetermined [ (Pending
Circumstances Investigation
.� Medical Certifier Name Title
Bernardo R.Villajuan Dr.
A. Address
88 Broad St, Glens Falls,NY 12804
ti: Death Certificate Filed District Numbe5601 Register Number
;: City, Town or Village Glens Falls 5- 60 ( I is'
❑Burial Date Cemetery or Crematory
March 12, 2014 Pine View Crematorium
❑Entombment Address
El Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
f_ Hold
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0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
[ I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
4*' Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
:: i 53 Quaker Road, Queensbury,NY 12804
:;] Name of Funeral Firm Making Disposition or to Whom
: Remains are Shipped, If Other than Above
Address
.*f; Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 11 Z/ ' L( Registrar of Vital Statistics W C '.Q \.AJ
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C,,:a (signatu e)
District Number 5601 Place Glens Falls N'
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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w Date of Disposition3 )3 IC/ Place of Disposition f)1/\J(
V re._ (A) E f“' '
W (address)
CO
(section) (lot number) (grave number)
p Name of Sexton o son in Charge of Premises
Z \ _ p/eas rint
Signature , 4� - Title
/ (over)
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DOH-1555(02/2004)