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Briggs, Wallace NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Wallace G. Briggs Male Date of Death Age If Veteran of U.S. Armed Forces, 08/11/2012 87 years War or Dates 1944-46 1-+ Place of Death Hospital, Institution or )OQ14I,1(Town or)fX1 X Rotterdam Street Address Dutch Manor Nursing Home 3 Manner of Death a Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending 111 Circumstances Investigation iti Medical Certifier Name Title Mirza, Ali Physician Acting On Behalf Of Attending Physic an Address 1940 Hamburg Street, Schenectady, Ny Death Certificate Filed District Number Register Number Mi) Town (A MAX Rotterdam 4654 70 ©Burial Date Cemetery or Crematory 08/16/2012 Pine View Cemetery ❑Entombment Address iii ❑Cremation Glens Falls, N Y Date Place Removed ❑Removal and/or Held N? and/or Address M Hold 0. Date Point of th❑Transportation Shipment 0 by Common Destination iin Carrier ❑Disinterment Date Cemetery Address ffii ❑Reinterment Date Cemetery Address Permit Issued to Registration Number IM Name of Funeral Home Catricala Funeral Home, Inc 00301 Address 1597 Rt. 9, Clifton Park, Ny 12065 j Name of Funeral Firm Making Disposition or to Whom - Remains are Shipped, If Other than Above Address c to Lt' Permission is hereby granted to dispose of the human re ins described ove as indicated. Date Issued 08/13/2012 Registrar of Vital Statistics U (signature) District Number 4654 Place Rotterdam ,.: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 8/1 6/1 2 Place of Disposition Pine View Cemetery 2 (address) Ul Ul Uncas Sec. 22 421 5 Cr (section) (lot number) (grave number) Name of Sexton or Perso harge of Premises Michael Genier (please print) 1 Si Signature . "�" Title Superintendent (over) DOH-1555 (02/2004)