Dashnaw Jr, Carl NEW YORK STATE DEPARTMENT OF HEALTH
it Vital Records Section Burial - Transit ermit
Name First Middle Last ' Sex
Carl N. Dashnaw,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 29, 2014 58 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death ❑Natural Cause LI Accident E Homicide n Suicide �Undetermined n Pending
Circumstances Investigation
w Medical Certifier Name Title
G Timothy Murphy,Coroner
Address
52 Haviland Ave.Glens Falls,NY 12801
Death Certificate Filed District Number R 's rmber
City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
❑Entombment July 2, 2014 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ El Removal and/or Held
and/or Address
E" Hold
O Date Point of
W0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Ei
Reinterment Date Cemetery Address
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
1- Remains are Shipped, If Other than Above
• Address
C
Q Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued -7 I i I i Registrar of Vital Statistics W C AA (signature) )
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui• Date of Disposition 1_Z fate Place of Disposition "t'^k0,44.4 C �t�
W (address)
Cl)
Et (section) (lot number) F (grave number)
a Name of Sexton or Person ' Charge of Premises I
s Jna.i'
Z' /1p ease print)
W7
Signature -- A Title
(over)
DOH-1555(02/2004)