Kyarsgaard, Victor NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
• Name First Middle Last Sex
Victor E.Kyarsgaard Male
Date of Death Age If Veteran of U.S.Armed Forces,
• 08/13/2018 84 Years War or Dates
Place of Death Hospital, Institution or
', City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause El Accident El Homicide El Suicide riUndetermined ri Pending
Circumstances Investigation
',. Medical Certifier Name Title
5 Shahid Ahmed MD
flO
Address
to 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
• City, Town or Villa•e Glens Falls 5601 386
❑Burial Date Cemetery or Crematory
�'4 08/14/2018 Pineview Crematorium
[]Entombment
Address
®Cremation Queensbury Town, New York
Date Place Removed
xl Removal and/or Held
and/or Address
• Hold
Date Point of
Q Transportation Shipment
p„ by Common Destination
Carrier
VA
Zii,Q Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
K. Permit Issued to Registration Number
144
• Name of Funeral Home Densmore Funeral Home Inc 00448
Address
x 7 Sherman Ave,Corinth,New York 12822
a . Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
,
3 p
Permission is hereby granted to dispose of the human remains described above as indicated.
_y$
• Date Issued 08/14/2018 Registrar of Vital Statistics �6enA Curtis(&Cectronicaf1ySigned)
(signature)
District Number 5601 Place Glens Falls, New York
w• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition $(I 1 lit Place of Disposition gig.. en.�tORw
E (address)
(section) ((]y�,'�(p�[t number) (grave number)
?? J�I r A ptxal_ SQ4A�
Name of Sexton or Person in Charge of Premises 9Pr
� (please rrnt)
1€ Signature ,,..4 r Title &OM IV-
(over)
DOH-1555(02/2004)