Straight, Gary Q. /1111 V
NEW YORK STATE DEPARTMENT OF HEALTH 1l
Vital Records Section Burial - Transit Permit
Name First Middle 47 Last Sex
GARY Q. STRAIGHT Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/18/21 64 War or,Dates
I;` Place of Death Hospital, Institution or Clear View Motel
WCity, Town or Village of So. Glens Falls Street Address 129 Saratoga Avenue
p Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
ILI Circumstances Investigation
W Medical Certifier Name Title
p George Siniapkin MD
Address
604 Palmer Ave, Corinth, NY 12822
Death Certificate Filed District Number Register Number
City, Town or Village of So. Glens Falls 4524
['Burial I Date Cemetery or Crematory
03/20/21 I Pineview Crematory
❑Entombment Address
iCremation Queensbury, NY .
Date Place Removed
Z ni Removal and/or Held
Dand/or Address
Cl) Hold
0 Date Point of
% ❑Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home , Inc. 00448
Address
7 Sherman Ave, Corinth, NY 12822
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
Address
CC
LLI
D. Permission is hereby granted to dispose of the human remai described above as in i to .
Date Issued 0 3/19/21 Registrar of Vital Statistics ,_(... /(,O,/ 1 ��
Village of (sign re)
District Number 4524 Place South Glens Falls , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Date of Disposition 3/7Z I tj Place of Disposition Z.tL .24`
,g (address)
W
(1)
cc (section) (1 number) (grave number
pName of Sexton or Person in Charge of Premis [A vs ' 3-i Art )
ZII. (pleaserint)
Ul
Signature Title jwlay+,. rl
(over)
DOH-t555 (02/2004)
I
Public Health Law Sec. 4145(2b) " _;- . 1 s.4i ��
Receipt
IHuman remains of delivered on , 20
Pine View Cemetery _..Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#