Myers, George R err ,
L It 31
NEW YORK STATE DEPARTMENT OF HEALTH \`',------ Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
George R Myers Male
Date of Death Age If Veteran of US.Armed Fortes,
01/07/2023 74 Years War or Dates
i_ Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital
p Manner of Death II Natural Cause Accident Ell Homicide Ei Suicide nUndetermined ri Pending
W
U Circumstances Investigation
G Medical Certifier Name Title
Hung Nguyen "\ MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed City Of Saratoga Springs t District Number Register Number
City,Town or Village 4501 18
Burial Date Cemete ity Name
01/10/2023 Pineview
Entombment Address
Cremation Queensbury Town,New York
Donation
ElRemoval Date Place Removed
and/or and/or Held
I-
- Hold Address
9
0
Q. Date Point of
Cl) Transportation
p by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
2 Address
CC
W
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/09/2023 Registrar of Vital Statistics Dillon Moran(Electronically Signed)
('signature)
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z L
W Date of Disposition I I lo)Z3 Place of Disposition „��
2 address)
W
CA
(section) JI (tot number/ (grave number)
gName of Sexton or Person in Cha Premises /A,\t`., t fl
Z ( se print)
W Signature Title ��'�M t`�l
DOH-1555(07/18)p 1 of 2
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#