Burlingame, Reginald NEW YORK STATE DEPARTMENT OF HEALTH 2
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Reginald Burlingame Male
Date of Death 1 Age ! If Veteran of U.S. Armed Forces,
January 28, 2012 ; 61 War or Dates
F- Place of Death I Hospital, Institution or
Z City, Town or Village Queensbury Street Address 100 Cronin Road
tp Manner of Death qNatural Cause Accident I I Homicide Suicide Undetermined Pending
�` Circumstances Investigation
w Medical Certifier Name Title
G Paul Bachman,Coroner
Address
Warrensburg,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657 II
❑Burial Date i Cemetery or Crematory
January 27, 2012 Pine View Crematory
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date I Place Removed
Z Removal
I and/or Held
and/or
Address
H Hold
u)
0 Date ' Point of
N 1 I Transportation I Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date I Cemetery Address
I
Permit Issued to 1 Registration Number
Name of Funeral Home Regan & Denny Funeral Home 1 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
M' Remains are Shipped, If Other than Above
2 Address
QL
ILI
Q` Permission is hereby granted to dispose of the human remai s described above indicated.
Date Issued I ',1D. ) r,),00- Registrar of Vital Statistics G , \
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance lwith this permit on:
W Date of Disposition 2/7 fit Place of Disposition PIN U C�. T ur,,,,
2 (address'
W
N
CL (section) (lot nu'per) (grave number)
pName of Sexton or Person in Charge of Premises t�s4 -{ Si itt
Z (please print)
W
Signature Title (124111.10t
(over)
DOH-1555(02/2004)