Garnsey Twin Boy B 1 Litt
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Twin Boy B Garnsey Male
Date of Death I Age If Veteran of U.S. Armed Forces,
8/30/2021 16 weeks War or Dates
H Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
W
Manner of Death n Natural Cause Accident n Homicide n Suicide n Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Dr Jennifer Bashant,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 (�
❑Burial Date Cemetery or Crematory
Entombment September 4, 2021 Pine View Crematorium
El Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal _ _ and/or Held
O and/or Address
H Hold
Cl)
O Date Point of
Nn Transportation _ Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
7 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
F_ Remains are Shipped, If Other than Above
2 Address
tt
LL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 91,3)/Z) Registrar of Vital Statistics Cs*4 I. ature)
District Number 6(0,0 Place G lei- a O S, N y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uiDate of Disposition Place of Disposition
W (address)
CO
CZ (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises
Z (please print)
W Signature Title
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#