Tippett Jr, Malvern NEW YORK STATE DEPARTMENT OF HEALTH + Burial - Transit �ermit
Vital Records Section
,, Name First Middle Last Sex
Malvern Edward Tippett,Jr , Male
e Date of Death Age If Veteran of U.S. Armed Forces,
Se'tember 4,2013 75 War or Dates
Place of Death Hospital, Institution or
-�, City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death n Natural Cause El Accident Homicide n Suicide n Undetermined n Pending
T1 Circumstances Investigation
_ Medical Certifier Name Title
jAddress
Death Certificate Filed ' District Number Register Number
City, Town or Village Glens Falls,NY 5601 t_58
❑Burial Date Cemetery or Crematory
ID Entombment September 6, 2013 Pine View Crematorium
Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Ci l Removal and/or Held
and/or Address
F Hold
N
0 Date Point of
N ❑Transportation 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
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ef; Permission is hereby granted to dispose of the human remains described above as-indicated.
f' Date Issued 9/6 I/.3 Registrar of Vital Statistics L �,4-,� c.�
, (signature)
/ District Number 5601 Place Glens Falls,NY
t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 6111I1> Place of Disposition iw,/ Lit w„
��U �Or
a (address)
Ui
U)
ILA
(section) 4 . (lot numbs (grave number)
a Name of Sexton or Person in harge of Prem" es ti �_ /.
1-41
2 lease print)
tt Signature Title CTttht
(over)
DOH-1555(02/2004)