Hamilton, Norman H NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sex
.._.........._.......Norma.n_........._..._ ... Hale.. Hamilton male
Date of Death....:..:....................::...::::::::: ;:::::::.........:::::::::.: , ::::::. :::.::: :::::::: :::::::::: ...........:::::::.:::.:::::::::::::::::::.
Age :: If Veteran of U.S.Armed Forces,
::::.:.;.:. 2_/.10/1990._.... ........ .. ........._73..........> War or Dates no
Place of Death Hospital, Institution or
. City,Town or Village `
..... :: ............::::::.....,::::9.;::::::::::::,C ty. of. Glens.: Falls ;: Street Address Glens Falls Hospital
C. Cause of Death
::::.........P...:.::..:..::::::..:.:::............:::::::::::.
.>:.::::::::::: cere:::ra :::.h morrha.ge.::::::::::::::..
,0: Medical Certifier Name Title:::::....................................................................
.................................
_..._......... _ -........................._...................................._....._...........
t
sG ._........_.............. DrPhi...... tiara. Jr.
.........................._.....................
................................
Address
:::::..:::::::::::::::::. : ::::7240...0 per...Broadwa ..,....Fort...Edward,....New York 12828
Upper...............:.......:......Y............::..:.::........:....:..............::....::::..:::::.:::::::::::::::::::::......::.:::::::.......::::::::::::::::::::::::::
Death Certificate Filed District Number : Regis Number
City,Town or Village Citv of Glens Falls G y
Date ', Cemetery or Crematory
❑Burial 2..12_..1990.._ Pine View Crematorium
:..:::::..:..::..1........1...: ..........:::::.:: > ::.................. ::::......._.._..._......_ _.. ._......._..........
.
❑-Cremation Address
Town of...Q.ueensb�r
Z; Date Place Removed
O; ❑ Removal ' and/or Held
and/or Hold'. :::::::::::::...._:::.....::::::.::::::::::::::::::::::.:::......::::::...:.:.::;>::::::::::::::::::::.::::.:::::.::::,:::::::..............:::::::.:......:::.......
:.:::::::::::::::::::::::::::::,::::::::::::.:::::::::::::::
' Address
t3 Date Point of
[]Transportation by:. Shipment
Common Carrier ....................................................................................................................................................................................................
..........................................................................................................................
Destination
................................. :.....ate::::::..................................................... ::.:::. ::::.Address::::::...................................................................................................
❑ Disinterment D Cemetery
.mete:::::Address:::::....................................................................................................
❑ Reinterment Date Cemetery
Permit Issued to Registration Number
Name of Funeral Firm Re an and Dennv Funeral Service Inc. 01634
Address
>' > 26 Quaker...Ro.ad. ...Queen.s_bur ......New...York...12804. ......::::::::::.:::::::::..:..:::::::::::::::::::::::::::::::::::.::::::::::::::.
............::::::......::.::......::::::...............W_...:::.................................:.,......:....:.....:..:...........Y..=...........................:.....::...::..::::...........
}_ Name of Funeral Firm Making Disposition or to Whom
.R Remains are Shipped, If Other than Above
.....................................................................................
Address
................................................
............................................................... ::::::..............
Permission is hereby granted to dispose of the hum ains descri d ab as indicated.
<> Date Issued 2/12/1990 Registrar of V'al Statistics 7.
(signature)
District Number Place zg'Pe
I certify that the remains of the decedent identified above weredisposed of in accordance with this permit on: j
Date of Disposition "/OZ` Place of Disposition
(address)
w
(section) (lot number) (grave number)
: hd A W_A_ Mz:g
pChargeTiP t�
: Name of Sexton r Person in of Premises
w Signature (please print)Title 1�I��/9
DOH-1555(9/86)p 1 of 2(formerly VS-61)