Virta, Eric NEW YORK STATE DEPARTMENT OF HEALTHlk 44 tic i
Vital Records Section 1 Burial - Transit Permit
Name First Middle Last Sex
Eric J. Virta Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 5,2013 I.S War or Dates
E,_ Place of Death Hospital, Institution or
Z City,Town or Village Lake George Street Address 483 Flat Rock Road
p. Manner of Death a Natural Cause ❑Accident ❑Homicide ❑Suicide 1-1 Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 T.Coppens
Address
3 Iron Gate,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Town of Lake George 5651 33(1
❑Burial Date Cemetery or Crematory
August 5,2013 Pine View Crematorium
❑EntombmentAddress
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
H Hold
N
O Date Point of
W ❑Transportation Shipment
a 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
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
Address
W
a' Permission is hereby granted to dispose of the huma emai described above as indicated.
Date Issued R7 L /3 Registrar of Vital Statistics yia-ft
(sign ure)
District Number 5651 Place Town of Lake George
I certify that the remains of the decedent identified above were disposed of in accordancee with this permit on:
W Date of Disposition q Is f 1 Place of Disposition /{�„�,V t� C.- r�
a (address)
W
Cl)
re (section) /�(to.t nuf'ber) ( (grave number)
QName of Sexton or Person ' Charge of P mises `ht rslt tnN1+
Z (plea print)
W Signature Title Clzav1 W.
(over)
DOH-1555(02/2004)