Gregoire, Jr. William IL
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
114 William A.Gregoire Jr. Male
>: Date of Death Age If Veteran of U.S.Armed Forces,
04/04/2018 70 Years War or Dates
Rz
. Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ID Accident ID Homicide 0 Suicide ri Undetermined �Pending
Circumstances Investigation
y Medical Certifier Name Title
' Farhana Kemal MD
ti,
Address
100 Park St,Glens Falls,New York 12801
€ Death Certificate Filed District Number Register Number
City, Town or Village Glens Fails 5601 171
"` _0 Burial Date Cemetery or Crematory
04/06/2018 Pineview Crematorium
2 .[]Entombment Address
4®Cremation Queensbury Town, New York
. Date Place Removed
Removal and/or Held
and/or Address
fxN
Hold
i} Date Point of
a
::Q Transportation Shipment
by Common Destination
•
E,= Carrier
Q Disinterment
Date Cemetery Address
El Reinterment Date Cemetery Address
d.
` Permit Issued to Registration Number
� Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
':. : Address
bi Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/06/2018 Registrar of Vital Statistics wp6ertACurtis(E(ectronicaQySigned)
tx£
(signature)
; .:' District Number 5601 Place Glens Fails, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition
�; p LIP lit Place of Disposition �.,u,., /t,,,,..s_
(address)
(section) a (lot number) (grave number)
Name of Sexton or Person in Charge of Premises l L.
a
d4..••1t
lease print)
Signature Title (go'Nll
(over)
DOH-1555 (02/2004)