Garnsey Twin Boy A e 161$1
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Twin Boy A Garnsey Male
Date of Death Age If Veteran of U.S. Armed Forces,
8/30/2021 16 weeks War or Dates
F., Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
O Manner of Death I X I Natural Cause E Accident n Homicide n Suicide n Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
O 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
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Placo ' moved
Z I I Removal Wld
and/or Address
H Hold
N
O Date oint of
O. n Transportation hipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 1 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
IF_ Remains are Shipped, If Other than Above
2 Address
W
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9)3)202.1 Registrar of Vital Statistics C10-52-y
(signature)
District Number I Place (ileac? la' 115,4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
iiI Date of Disposition ' l I Place of Disposition et7A.di _
W (address)
N
O (section) of rWmb?r) St,14.4itt (grave number)
pName of Sexton or Person in Charge of Premi , n v L
Z (please
W Signature A Title liftY'x'iiiq
(over)
DOH-1555(02/2004)
0IJ , .. S.
Public Health Law Sec. 4145(2b)
Receipt
Human remains of T delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#