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Slory, Bertus -4 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex in be,r s 5\ury t� 0Date of Death Age I If Veteran of U.S. Armed Forces. 03/0 3 I I le, Cr)._ i War or Dates Place of Death Hospital, Institution or M 1 , f Ci Tow. or Village Q�;e s'ot r y Street Address _ 1(1 e �\-g y1 Th-O • �1 a, Manner of Death kg Natural Cause 0 Accident Homicide Suicide Undetermined Pending s kg Circumstances Investigation Medical Certifier Name Title 0 R 0S\��f\ SOC of CC M� Address S -c -c Ill i i ' &Nix PACin. Nvt aeerSlotr , M z$oy S Death Ce ificate Filed District Number Re . er NUti ber City ow r Village Qu y'S\p»r y , --1 o .` ' ' Date / Cemetery or Crematory : rA Burial D 10 I oZO)lQ FiYID `):Pv3 e. 'rl( Address DCremation QVe_ersbo 1--.4 , N 12$CS4 Date j PlaceRemoved 0❑Removal I and/or Held -• and/or Address }=' Hold tO 0 Date Point of • Transportation, i Shipment a by Common Destination • Carrier :: Disinterment Date Cemetery Address El Reinterment I Date Cemetery Address «; Permit Issued to ;� Registration Number <` Name of Funeral Home _ L)P ri..- t_ _xi er 31.1, f '1 t ©!/39 Address / ii L i &A�J/C)-7 L:- C? 62 U6"t:.r3S Ci u r-e ' , f 2.8 `/ ><>� Name of Funeral Fjim Making Disposition or to Whom Remains are Shipped, If Other than Above ` ' U . Address felPermission is hereby granted to dispose of the human femains described ab ye as indicated. Date Issued 31 IO)(p Registrar of Vital Statistics C--\ tl.`� (si natu e) � �<<� District Numbei��Zp�'� Place ( ® ry.M c54, I certify that the remains of the decedent identified above were disposed of in accordan a wi this permit on: F WDate of Disposition 3/1 0/1 6 Place of Disposition Pine View Cemetery, Queensbury, NY 2 (address) W Erie 1H 1 fX (section) (lot number) (grave number) Name of Se ton or Person in Charge of Premisesin Connie. L. Goedert (please print) 44 Signatur 12.2LAQ Gt_. Title Cemetery Superintendent (over) DOH-1555 (9/98)