Foote, Ronald r NEW YORK STATE DEPARTMENT OF HEALTI'M ; 473 7
3 fi
Vital Records Section .:
Burial - Transit Permit
lilllili Name First Middle Last Sex
Ronald • Eric Foote Male
Date of Death Age If Veteran of U.S. Armed Forces,
56 years War or Dates
{- Place of Death3 Hospital, Institution or
Z City, Tow i -;- Street Address Glens Falls Hospital
W. Itk) •�XX Glens F p
Manner o ea h 1 Natural Cause Accident Homicide Suicide Undetermined ❑Pending
ll Circumstances Investigation
IJ Medical Certifier Name Title
Robert W. Sponzo M. D.
Address
102 Park Street Glens Falls, Ny 12801
Ni Death Certificate Filed District Number Register Number
gii City, TowujiyiI XX Glens Falls 56n1 714
ii.i ''❑Burial `bate Cemetery or Crematory
":❑Entombment 05/17/2013 Pipe View CrPmatnriiim
Address
' •
'SIC emation Queensbury, NY 17804
Date Place Removed
❑Ho Removal and/or Held
w"
and/or Address
ld
t;
- Date Point of
call Lir-1 Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Eiii ❑Reinterment Date Cemetery Address
i!iigPermit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
iiig Address
P n Roy 277 Fort Ann N Y 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
ill
CL
ii]iii Permission is hereby granted to dispose of the human remains described above as indicated.
iiiigil Date Issued n5/16/2013 Registrar of Vital Statistics ,3 C '..A.)
signature
District Number Place
lig 5601 Glnns Falls N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition '1 i3 Disposition _^
p fj I Place of 4.a�s Ivr+t Ot',u'...
(address)
LU
CO
C (section) ,Di (lot number) µ (grave number)
!
Name of Sexton or Per on in Charge of Premises 4r4s}d iii,rat
z (pi ase print)
atk
Signature l.. Title Cr'iEf�YI�g
(over)
DOH-1555 (02/2004)