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Madison, Wayne A
.4 . __ , • , # , NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Wayne A Madison Male Date of Death Age If Veteran of US.Armed Forces, 12/31/2023 62 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital W Manner of Death � W Natural Cause ❑Accident El Homicide Ej Suicide Undetermined ri Pending V Circumstances Investigation W Medical Certifier Name Title Q Scott Biasetti MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 618 Burial Date Cemetery,Crematory or Facility Name 01/03/2024 Pineview Crematory Entombment Address ©Cremation Queensbury Town,New York DDonation 0❑Removal Date Place Removed and/or and/or Held F. N Hold Address R U)❑Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment 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 IE W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/02/2024 Registrar of Vital Statistics Megan Nolin(Electronically Signed) (signature) District Number 5601 Place City Of Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition 114 11.3 Place of Disposition IV646 J jrritilik W 2 (address) W CC N (section) (lot number) (grave number) 8 Name of Sexton or Person in Charge of P ' es / . St".. Z f (, ease print) /^ Ill Signature Title e '"l'9 DOH-1555(07/18)p 1 of 2 I !n 9✓ 9 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#