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Colchester, Art NEW YORK STATE DEPARTMENT OF HEALTH -' `, l t 7S Vital Records Section Burial - Transit Permit Name First Middle Last Sex Art Colchester Male Date of Death Age If Veteran of U.S. Armed Forces, December 9, 2013 69 War or Dates p... Place of Death Hospital, institution or Z City, Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death� Natural Cause Accident Homicide n Suicide n Undetermined I I Pending W Circumstances Investigation W Medical Certifier Name Title C1 Christopher Hoy Address 102 Park Street,Glens Falls,NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 .53 ) ❑Burial Date Cemetery or Crematory December 12, 2013 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed z n Removal and/or Held and/or Address t— Hold 0 Date Point of yn Transportation Shipment p by Common Destination Carrier n 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 I— Remains are Shipped, If Other than Above 2 Address Le IQ IL Permission is hereb granted to dispose of the human r(mains d cribe above as indi . •. Date Issued �ai( „`?Gym Registrar of Vital Statistics _i , 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: Lu r Date of Disposition )l3)13 •Place of Disposition £t,,,,, �IYr,tat...- 2 (address) CO11.1 Q (section) /f, (IQtnumbe (grave number) Name of Sexton or Person in Charge Premises „t„, JI.,40- Z lease print) ILI Signature 4 C Title aVAIYide (over) DOH-1555(02/2004)