Ettinger, Henry w, r ei 9
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' NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
•ii'i Name First i i 4Middle �/� _ Last Sex )�
Date of Death /j' Ag If Veteran of U.S. Armed Forces,
�-/l// War or Dates
!ii:.:•! Place of Death Hos ital, Institution or /ACity, T�ge glehS l G 1/5 Street Address /// l®C£ 4i 7" v<
to
cli Manner of Death Z,Natural Cause 0 Accident 0 Homicide 0 Suicide ElUndetermined El Pending
{ Circumstances Investigation
Medical Certifier Name Ti e4
o f-ei,1 San2--it
AddressiM
i
Death Certificate Filed J District Numb r Register Number
iiiii City, Touw�-or-'diiinge f1i l �f��� .`l 6 0 f
Date /� Cemeter Cremato
`: Burial d`/7 "/6 h.L /e4r/ eebn L kr--7
Address /j'� � /
❑Cremation / G,� Vee ti f �� / `f"
.. Date P e�Removed
2❑Removal and/or Held
and/or Address
Hold
0 Date Point of
NQ Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to c / / ,t I / n Regis r tion Number
liUl Name of Funeral Ho e v `l/Vqh &?tb1„..6„, 1 6/� a 77
li Address /' 7 a rli 51', geoli I; 4 N al--,
'„„, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
41- Address
I
:].:•i,i,K Permission is h reby grao dispose of the human remains described abov as indi ted.
ifil
iiiiR Date issued 7- / /I Registrar of Vital Statistics
` � (signature) /�/�
District Number 5-100/ Place -e'�o a2 / /1,y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
W Date of Disposition 2/13/95PIace of Disposition Pine View Cemetery Queensbury NY 12804
2 (address)
LL! Mohican 85—E 1
CC (section) (lot number) (grave number)
GName of Sextoit •r Person in Charge of Premises Rodney G. Mosher
z (please print)
W Signature = Title Supt .
•
DOH-1555 (10/89) p. 1 of 2 VS-61