Hitzegrad, Glenn , OF , 41 io Z
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
s Name First Middle Last Sex
Glenn Hitzegrad Male
>' Date of Death Age If Veteran of U.S. Armed Forces,
05 / 14 / 2018 68 War or Dates N/A
}- Place of Death Hospital, Institution or
iTi City, Town or Village Lake Luzerne Street Address 42 Davern Dr. , Apt 7
0 Manner of Death®Natural Cause Accident Homicide E Suicide Undetermined Pending
Circumstances Investigation
ui Medical Certifier Name Title
Desmond Rudolph Delgiacco MD
Address
59 Myrtle St # 300, Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number,--,City, Town or Village Lake Luzerne ����
<: 7
UBurial Date Cemetery or Crematory
05 / 21 / 2018 Pine View Crematory
`? ?OEntombment Address
IXCremation Queensbury, NY
, Date Place Removed
Z❑Removal and/or Held
` and/or Address
Hold
0 Date Point of
giQ Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
q. Address
402 Maple Ave., Saratoga Sp. , NY 12866
li Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a. Address
ICI
111
" Permission is hereby granted to dispose of the huma ainsd escr' ed ab a indicated. i
Date Issued ,c�/ IS Registrar of Vital Statisti fi /�/ �.2
Z
_ '
7 (signature)
District Number SA3Z2 Place Lake Luzerne , New York
1100.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 5/iLIt1 Place of Disposition evii... L
ai (address)
tel
0 CC (section) 1#1 number) r._ (grave number)
Name of Sexton or Person in Charge o Premises (1e -.,. }
(pie a print) •
ii
Signature Title 144401
(over)
DOH-1555 (02/2004)