Siefker, Gregg NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gregg Russell Siefker
Date of Death Age If Veteran of U.S. Armed Forces,
Augus t21 , 1999 52 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death n Natural Cause Accident ❑Homicide ❑Suicide 0 Undetermined Pending
_ Circumstances Investigation
Medical Certifier Name Title
_Todd Duthaler MD _
Address
211 Church St Saratoga Springs , NY 12866
Death Certificate Filed District Number RegistejVjer
City, Town or Village Saratoga Springs 4501
Date Cemetery or Crematory
El Burial August 24, 1999 Pineview Crematorium
Address
®Cremation Quaker Rd Queensbury, NY
Date Place Removed
8❑Removal and/or Held
••• and/or Address
Hold
Q Date Point of
NQ Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Tunison Funeral Home 01930
[[' Address
105 Lake Ave Saratoga Springs , NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ain iscriibed a as indicated.
Date Issued 8/2 3/19 9 9 Registrar of Vital Statistics
( # ature)
District Number 4501 Place Public Safety , Saratoga Springs , NY 12866
I certify that the remains of the decedent identified above wer,e/disposed of in accordance with this permiton::
z Date of Disposition Place of DispositionW. )
W (address)
LIJ
(section) 4 n (lot number) (grave number)
G Name of Sexton or Person i Charge of Pre ises �1)/ /�
(please print)
.W Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61