Dean, Willaim R •
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
William R.Dean Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/22/2021 65 Years War or Dates
Place of Death Hospital,Institution or
,Z City,Town or Village Lake George Village Street Address 168 Ottawa Street 3,Lake George Village,New York 12845
p Manner of Death 0 Natural Cause ❑Accident El Homicide Ei Suicide ❑Undetermined Ei Pending
U,1 Circumstances Investigation
C.)
W Medical Certifier Name Title
CI Tanya Finch NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Lake George Village 5620 6
❑Burial Date Cemetery,Crematory or Facility Name
08/25/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
Donation
Date Place Removed
O Removal❑ and/or Held
H and/or
v)
Hold Address
0
Date Point of
U) 11 Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
❑Disinterment
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
M Address
CC
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/25/2021 Registrar of Vital Statistics rDe6ra.Afc,Einney(ElectronicallySWned)
(signature)
District Number 5620 Place Lake George Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition Place of Disposition D; e� �;
f (address)
Ui
CO (section) (lot number) (grave number)
G Name of Sexton or Person in Charge of Premises <rt" ' 5'
(please print)
W Signature Title Ct�"'`Ye',
DOH-1555(o7/t8)p t of 2
1_ 5078
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
--Pine Viet Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#