Gustine, Hershel At IT
NEW YORK STATE DEPARTMENT OF HEALTH -TN
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Hershel I,. Gusti a Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 10, 2013 81 War or Dates yes
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Gl Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
u Medical Certifier Name Title
Suzanne Rayeski,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 S Lj 9
❑Burial Date Cemetery or Crematory
December 18, 2013 Pine View Crematory
❑Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NI I 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
.1 Remains are Shipped, If Other than Above
Address
CZ
Ili
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 2//S-j/3 Registrar of Vital Statistics W W
(sign ure)
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:
z 'F 1) J Cw.`tor, ,
W Date of Disposition (1-te-i3 Place of Disposition
2 (address)
W
CO
O (section) number) (grave number)
p Name of Sexton or Perso in Charge Premises 4r(ilo:
— .�t►ti✓14
Z (plea�e print)
W
Signature ii_ C Title 4,FTPA� °e2
(over)
DOH-1555(02/2004)