Tavares, Manuel NEW YORK STATE DEPARTMENT OF HEALTH " r /t 59(
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Manuel Tavares Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 10,2012 87 War or Dates No
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
WI Manner of Death X Natural Cause n Accident In Homicide Suicide n Undetermined Pending
Circumstances Investigation
gMedical Certifier Name Title
P; Dean Reali MD
Address
100 Park St. Glens Falls
; ; Death Certificate Filed District Number Register N mber
City, Town or Village Glens Falls 5601 w
❑Burial Date Cemetery or Crematory
❑Entombment November 13,2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z U Removal and/or Held
O and/or Address
E Hold
N
O Date Point of
es I 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
h+, Remains are Shipped, If Other than Above
3 Address
Ui
: Permission is he eby granted to dispose of the human rGemains escribed bove as i dica'-d.
Date Issued // /,3 ` / Registrar of Vital Statistics p �.,� �i/ 42%
(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:
WDate of Disposition /)/tS/it. Place of Disposition ?jot 014,4 CrIA40rl,;,�,
2 (address)
W
CO
CL (section) /j -(lot number) (' (grave number)
Q Name of Sexton or Person in Charge of Premises G/1j t,ii J t n+�tli-
ase print)
W
Signature 1 11' Title CR,e N114TOQ
(over)
DOH-1555(02/2004)