Hay, Peter R NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
..........Ret.e.r..::........:..:........._ ...R.e.dgewell...:..::. -::.:::. .....a male
.. ......:.:
Date of Death Age If Veteran of U.S. rrned Forces,
April 18 1991 76 War or Dates
:.::.:.......... �..............._. :: ...... .... ... ...... :.............:..---n�......:::...
.. .- ........
Z Place of Death Hospital, Institution or
W City Town or Village City of Glens Falls Street Address G1enS:::Fa11s..Hospita.l::.,
G Mariner of Death............................. Undetermined Pending
4U Natural Cause Accident Homicide Suicide g
Circumstances Investigation
..:.:.:. ......... .. .... ..... . ............. .... ......
tLf Medical Certifier Name Title
p __ .John.._R.u.gge _ MD
.. -::::::... ...... ........................................................... -. ............
Address
........ ...:....:.....: ................. Warrensburg..,::N. . Y:•:::. _.:.::. ................
Death Certificate Filed District Number Register Number
City,Town or Village City of Glens Falls
Date Cemetery or Crematory
❑Burial Pine .View Cremator
A.pr.il �9 r �991:: : ........:: y....::.
®Cremation Address
Town of Queensbury, N _Y, .
.......... _:.::::. :::::::.
Z Date Place Removed
O ❑ Removal and/or Held
F- and/or Hold ::::::.
Address
N
0........ ...................................
a Date Point of
N ❑Transportation by Shipment
p: Common Carrier _ ............ :: _..:. ............
Destination
....-
❑ Disinterment Date Cemetery Address
.........
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm _Regan.:,a.nd.:.penra.y Fun..er.a.l...Suc. ,:.._Inc.._..... 01634
.. ....
Address
26 Quaker Road, Queensbury, N. Y. 12804
...... . .........:............ ......
#- Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
... . .......................: ........ . ........:........ _ ........
Address
U]:
d_
Permission Is hereby granted to dispose of the huma re ains scribed ab a as indicat d.
Date Issued — Registrar of Vital Statistics �
signature)
District Number Place
'16P eel
I certify that the remains of the decedent identified above were disposed of i cordance with this permit on:
Z Date of Disposition '� '� Place of Disposition �%�✓.� l/J / �/ /�7 ��
«2 (address)
w'
0 (section) (lot number) (grave number)
cc
p' Name of Sexton or erson in harge of Premi s �1�/g/f
Z' (please print)
w` Signature Title��.�i� �C]�('� ✓.��f/
DOH-1555 (10/89) p. 1 of 2 VS-61