Maille, Gary NEW YORK STATE DEPARTMENT OF HEALTH , f 313
Vital Records Section Burial - Transit Permit
j. Name First Middle Last Sex
Ga Earl Maine Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 11, 2013 47 War or Dates Marine
40 Place of Death Hospital, Institution or
Cit ,Town or Village Glens Falls NY Street Address Glens Falls nos ital
Manner of Death Q Natural Cause Accident n Homicide Suicide n Undetermined Pending
,,,.
e„, Circumstances Investigation
41' Medical Certifier Name Title
Gary Scidmore,Coroner
s Address
j Lake George,NY
s' Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY _ 5601 c1_[.4) •
❑Burlai Date Cemetery or Crematory
[�Entombment July 15,2013 Pine View Crematory —
Address
NI Cremation Quaker Road, Queeensbury,NY 12804
Date Place Removed
Z u Removal and/or Held
and/or Address
M; Hold
0
ta — Date Point of
<
Transportation Shipment
ci by Common Destination
Carrier
Disinterment Date Cemetery Address
'.ri Renterment Date Cemetery Address
ss Registration,� Permit Issued to g tertian Number
'0 Name of Funeral Home Regan Denny Stafford Funeral Home 01443
k Address
• 53 Quaker Road,Queensbury,NY 12804
ei
A. Name of Funeral Firm Making Disposition or to Whom
ai Remains are Shipped, If Other than Above
Address
v
S
e�, I Permission is hereby granted to dispose of the human remains dewbe ab e a I sated.
;; �
Date Issued 0�I Registrar of Vital Statistics
Jo. (signature)
0
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of In accordance with this permit on:
W Date of Disposition 1- IL-I3 Place of Disposition Z41L i framer`
2, (address)
III&, (section) (lot ny�be) ( rave number)
Name of Sexton or Person In Charge of Pre ises li r
a, (please prin
W Signature Title C "Wink
(over)
DOH-1555(02/2004)