Sanders, Gary A NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Gary A.Sanders Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/25/2021 57 Years War or Dates
f. Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 21 Briwood Circle,Queensbury Town,New York 12804
pManner of Death ID Natural Cause El Accident 1=I Homicide 11 Suicide El Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
0 Melanie Duerr NP
Address
47 Tom Phelps Lane,Mineville Hamlet,New York 12996
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 251
❑Burial Date Cemetery,Crematory or Facility Name
12/28/2021 Pine View Crematory
El Entombment Address
Cremation Queensbury Town,New York
ElDonation
Z❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
13 Date Point of
co ❑Transportation
a by Common Shipment
Carrier Destination
12 Disinterment Date Cemetery Address
ElReinterment 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
Remains are Shipped,If Other than Above
a Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/28/2021 Registrar of Vital Statistics Caroline 9Ii fegard Bader(ElectronicalySigned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition w?_a%_Zcz t Place of Disposition iP—I ,� e t`,�u„� C reinq 40 �;
2 (address)
W
(section) (lot number) (grave number)
�,f
• Name of Sexton or Person in Charge of Premise Rf�7 D r�
(please pnnt
• Signature ,m/" A Title 0fe.747
DOH-1555(o7/18)p t of 2
i !: 1.
Public Health Law Sec. 4145(2b)
Receipt
1 Human remains of delivered on , 20
tj
1443
>l
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#