Varney, Dale NEW YORK STATE DEPARTMENT OF HEALTHt. ���
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dale J. Varney Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 23, 2012 61 War or Dates
'9 Place of Death Hospital, Institution or
City, Town or Village South Glens Falls 1 Street Address 20 Circle Dr.
ciManner of Death n Natural Cause _Accident n Homicide X Suicide Undetermined Pending
i3 Circumstances Investigation
u Medical Certifier Name Title
Cl. Michael Sikirica,MD
Address
Saratoga Medical County Coroner
Death Certificate Filed District Number Register Number
City, Town or Village South Glens Falls 71
❑Burial Date Cemetery or Crematory
July 25, 2012 Pine View Crematorium
❑Entombment Address
❑X Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
co
O I Date Point of
N Transportation Shipment
6 by Common Destination
Carrier _
n Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
N' Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
X Address
dG
U
Permission is hereby grant to i P se of the human rem ' s described above a indicated.
Date Issued °7�/ Registrar of Vital Statistics ex_12_,....
(signature)
District Number /74‘... c2 y Place South Glens Falls i 1 (1 1 03
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition -i_Z` �f,
-j2 Place of Disposition Mtki.4 Cri-gforow-
W (address)
CO
O (section) if r (lot number)oi (grave number)
p• Name of Sexton or Person in Charge of Premises thfr rr t •.4If
Z (please print)
W Signature al?L Title ON@MAToll.
(over)
DOH-1555(02/2004)