Forney, Nehemiah Psalm NEW YORK STATE DEPARTMENT OF HEALTH NZ ?
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nehemiah Psalm Forney Male
Date of Death Age If Veteran of U.S. Armed Forces,
5/17/2023 0 War or Dates
1., Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death ' Natural Cause pi Accident _ Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
wwj Medical Certifier Name Title
C Dr McAndrews,DO
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
I
City, Town or Village Glens Falls,NY 5601 G-
❑Burial Date Cemetery or Crematory
❑Entombment May 19, 2023 Pine View Crematorium
Address
Ni Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
U)
d Date Point of
to ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑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
N Remains are Shipped, If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human re al described ab ve as indicated.
Date Issued .51/4 .A 3 Registrar of Vital Statistics it
�' i ((signature)
District Number O/ Place Glens I/�S/ Pt_J Z(sd
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LuDate of Disposition Si 14! Z3 Place of Disposition '�i�l,/�
W (address)
U)
CC (section) J (lot number) (grave number)
pName of Sexton or Person in Charge of Premises /�S1 L._ .-1H
Z please print)
W Signature Title fr2v►'''1Hr6
(over)
DOH-1555(02/2004)
I Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#