Corhouse, Sam t IF (Ai
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sam Corhouse Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 23, 2012 79 War or Dates
1,,, Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death 17 Natural Cause n Accident Homicide Suicide n Undetermined Pending
W Circumstances Investigation
�, Medical Certifier Name �� � Title
G ri P
AcLdress ,�,�
100 ?Fw(C ST ACV t'e}Ctf t=-� 12161
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 5 Fcct
❑Burial Date Cemetery or Crematory
December 26, 2012 Pine View Crematory
❑Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12801
Date Place Removed
Z ❑Removal and/or Held
and/or Address
F" Hold
CO
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
El
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
r5 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
g Address
It
O. Permission is hereby granted to dispose of the human remains described above es indicated.
Date Issued ) 2 2 26 !/2 Registrar of Vital Statistics CM4 \A)N^
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition tt-fl i2 Place of Disposition Z., itLw 6Gw4 rill,,
W (address)
co
re
(section) Ar lot number) (grave number)
pName of Sexton or Person in Charge of Premises )� .cakui -
Z (plehse print)
LU L_
Signature �,p Title C >}TDQ
r (over)
DOH-1555(02/2004)