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DeWitt, Norman LILT NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section } __ Burial - Transit Permit Name First Middle Last ' Sex im NORMAN EARL DeWITT MALE Date of Death Age If Veteran of U.S. Armed Forces, iiiii OCT. 19, 2006 75 War or Dates WW 2 & Korea Place of Death Hospital, Institution or -6 , Towne Harrietstown Street Address Adr ' Ir. Medical Center ci Manner of Death ® Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Ui Circumstances Investigation uj• Medical Certifier Name Title 0 H. V. W. BERGAMINIL MD. Address SWISS ROAD, LAKE PrACID. NY Death Certificate Filed District Number Register Number iiiiiiiiii may, Town ce-Village HARRIETSTOWN 1663 Date Cemetery or Crematory ❑Burial OCT. 23 , 2006 PINE VIEW CREMATORY Address ©Cremation GLENS FALLS, NY Date Place Removed O ❑Removal and/or Held and/or Address r" Hold 0 O ' Date Point of N ❑Transportation Shipment 5 by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address <` Permit Issued to Registration Number Name of Funeral Home. `�' B. CLARK, INC. 01146 Address 2310 SARANAC AVE. , LAKE PLACID, NY iiiiiii > Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 16 Address W X iiiiiiii Permission is hereby granted to dispose of the human re ins describe above indicated. Date Issued 1 0/21/06 Registrar of Vital Statistics .* , A A ' 7*' (signature) I iNi District Number 16 6 3 Place -, 0Ci c Z-- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: !- WDate of Disposition i4)/.3/oi Place of Disposition 7,n 10'J (:4-v.-wj`rJrr,0•. 2 (address) ill N CC (section) (lot number) (grave number) O Name of Sexton or Person in Charge of Premises CI- Ts ' -t.Y,7, (please print) W :`Signature ( . .n.,C-, Title (r •-t-n..fvr (over) DOH-1555 (9/98)