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Reynolds, Eric NEW YORK STATE DEPARTMENT OF HEALTH r 1 ft �1Vital Records Section Burial - Transit Permit Name First Middle Last Sex Eric Whitford Reynolds Male Date of Death Age If Veteran of U.S. Armed Forces, October 19, 2013 61 War or Dates I,.,, Place of Death Hospital, Institution or Z City, Town or Village Queensbury Street Address 3 Westmore Ave 'p Manner of Death Natural Cause ❑Accident ❑Homicide 0 Suicide )Undetermined )Pending Circumstances Investigation ui Medical Certifier Name Title Craig Emblage MD Address Three Irongate Center,Glens Falls,NY 12801 Death Certificate Filed Queensbury District Number Register Number City, Town or Village 5657 `` ❑Burial Date Cemetery or Crematory ❑Entombment October 21,2013 Pine View Crematorium Address ©Cremation 21 Quaker Road,Queensbury,NY 12804 Date Place Removed ZO ❑Removal and/or Held and/or Address E Hold N 0 Date Point of N ❑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 i- Remains are Shipped, If Other than Above 2 Address CZ al f1 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 16'� ) Registrar of Vital Statistics -K�_ �-�t , C 6 n' (signature) District Number 5657 Place Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: wDate of Disposition Minh, Place of Disposition -nsJuyAJ C rA.... W (address) pCl) (section) f:" (lot numb") (grave number) Name of Sexton or Person in harge of Pr mises ,� L Z (lease print) u1 Signature Title Ceeh►4Tl< (over) DOH-1555(02/2004)