Bolz, Matthew 11/06/2017 08:29 5183773446 f 1111 LIGHTS FUNERAL HOME PAGE 01/01
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Kermit
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=F Name First Middle Last I Sex
4- MATTHEW WILLIAM BOLZ MALE
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4•., Date of Death - Age- If Veteran of U.S. Armed Forces,
< t 11/2/2017 19 War or Dates -
P• lace of Death Hospital, Institution or
C• - ,Town or Village ALBANY Street Address ALBANY MEDICAL CENTER
r:fa' Manner of Death❑Natural Cause ®Accident Q Homicide Suicide El Undetermined ❑Pending
i"_ Circumstances Investigation
Medical Certifier Name Title '
N.."BALASDR:'.BRANA.N AM.MD
3s7i Address
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: . Death Certificate Filed -6 District Nuthber i Register Number
' City,Town or Village 'i 1j o►» _
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# . Burial Date Cemetery or Crematorr�
%-. 11/6/2017 pin VIEW CREMATORY
-UEntombment -
Address
Cremation '
r••;,•
�,: Date Place Removed
Removal '
and/or Held
,, and/or Address
'r° Hold
Date Point of
- ❑Transportation Shipment
• by Common stination
" Carrier _
, Date Cemeteryd
r El Disinterment
Address
Date Cemetery Address
';❑Reinterment
• Permit Issued to i
.. Registration Number
x
r; Name of Funeral Homev)} f - � •� V IS-q C
": A• ddress
Name of Funeral Finn ak'�" Disposition or to Whom •
R• emains are Shipped, . .
»� piled, If Other than Above
-,Sr Permission is h re y granted to dispose of the human s de cr ded above as Indicated
> ,< Date Issued / Registrar at Vital Statistics /`,
nk;E,
(sign .re)
District Number Place
.:. I certify that the remains of tie decedent identified above were disposed of in accordance with this permit on:
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r. Date of Disposition• it i i 11? Place of Disposition - f imy I 6- l6'riw ..' _
(4dareev
s
. (section) jlot numb (grave number)
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Name of Sexton or Person in Charge of Pre ises _ G�r+� r /A^/4
Signature �'` Title _ M1 r)Arf/L
(over)