Eggleston, Elmer — 4gY
NEW YORK STATE DEPARTMENT OF HEALTH 3
N
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elmer . Eggleston Male
Date of Death Age If Veteran of U.S. Armed Forces,
i March 12, 2014 91 War or Dates World War II
Place of Death Hospital, Institution or
i
City, Town or Village Glens Falls Street Address Glens Falls Hospital
gManner of Death I XI Natural Cause I !Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
i Medical Certifier Name Title
Phillip J. Gara Dr.
Address
327 Broadway,Fort Edward,NY 12828
:. Register
f oorr Death Certificate Filed District Number Register Nu ber
City, Town or Village Glens Falls 5601
❑Burial Date , Cemetery or Crematory
March 18, 2014 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
NTransportation , Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
ii 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
t*; Remains are Shipped, If Other than Above
Address
�: Permission is hereby granted to dispose of the human remains described above as indicated.
`
Date Issued S ) i `i ) ILf Registrar of Vital Statistics LA?C'0 ` l.,� �-a
(sign�� attire)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above w e disposed of in accordance with this permit on:
W Date of Disposition)9-// Place of Disposition i/2/4 //,,-./ ��
2 (address)
W
N
pre (section) S'iG (/e�num er) (grave number)
Name of Sexton o rson i rge of Premises �((/v+.✓
`Z pAlease priin/t�_,i
Signature jf I Ai� Title �vg, !" 5/'
(over)
DOH-1555(02/2004)