Converse, Randy NEW YORK STATE DEPARTMENT OF HEALTH , Nlr�
Vital Records Section
Burial - Transit Permit
Name First Middle Last Sex
Randy K. Converse Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 18,2014 57 War or Dates
; Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
IS Manner of Death � Undetermined Pending
�I Natural Cause Accident n Homicide Suicide
Alt Circumstances Investigation
w Medical Certifier Name Title
4 Timothy E.Murphy Mr
Address
52 Haveland Ave.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls Re 5601 -7 9
❑Burial Date Cemetery or Crematory
February 20,2014 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
u)
0 Date Point of
NTransportation Shipment
..Th
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
a? Name of Funeral Home Alexander-Baker Funeral Home 00037
.1 Address
, 3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
#.•: Remains are Shipped, If Other than Above
is Address
tit
Permission is helreby granted to dispose of the human remains described above as indicated.
Date Issued 2 12C) 1/L) Registrar of Vital Statistics �Gvu,r.c VJ
gnature)
,, District Number 5601 Place Glens Fallss�
I certify that the remains of the decedent identified above were disposed
of in accordance with this permit on:
Z -Date of Disposition ��dl�i� Place of Disposition .�
W (address)
U)
pr (section) �f � / (lot number) (grave number)
Name of Sexton or Person in Charge of Premises r,Ntc(�. !milt
ZJ d
r (please print)
wSignature Title CffWtde.
(over)
DOH-1555 (02/2004)