Holden, Austin �/1
*
NEW YORK STATE DEPARTMENT OF HEALTH ` s
Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
Austin Edward Holden Male
Date of Death Age If Veteran of U.S.Armed Forces,
June 24,2006 75 War or Dates
Place of Death Hospital, Institution or
jk' City of Glens Falls Glens Falls Hospital
z City, Town or Village Street Address
Manner of Death X Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
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CA Medical Certifier Name Title
Address
Death Certificate Filed District Number / Register N m•r
City, Town or Village Glens Falls,New York 5601 r •
0 Burial Date Cemetery or Crematory
6/28/2006 Pine View Cremation
❑ Entombment Address
El Cremation Queensbury,NY
Date Place Removed
Z ❑ Removal and/or Held
O and/or Address
1:. Hold
aN Date Point of
❑ Transportation Shipment
V) by Common Destination
G Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Sullivan Minahan&Potter 01734
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IP Permission is hereby ran ed to dispose of the human remains described ,��indied.
2
Date Issued ®6 6 Registrar of Vital Statistics //
(signature)
? District Number 5601 Place Glens Falls,New York
,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition tee-Z�NO . Place of Disposition Ps cgs Yi-w Q �12 k5,✓6 )4-t:6 2 y;9 41,
LU
LU (address)
LU
N (section) (lot number) (grave number)
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0 Name of Sexton or Person in Charge of Premises 0- 4 2
19 a 1�,L`1y i
(please print) 1
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LU Signature C9-ht.vt(7. a,L Title (1v,GL/4r 11''Oi?
DOH-1555(02/2004) (over)