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Andrews, Wilbert NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Wilbert Andrews Male Date of Death Age If Veteran of U.S. Armed Forces, February 26, 2017 58 War or Dates n/a Place of Death Hospital, Institution or City, Town or Village Moreau Street Address Manner of Death i—li I Natural Cause ❑Accident n Homicide n Suicide n Undetermined n Pending Circumstances Investigation ?' Medical Certifier Name Title Michael Sikirica,Medical Examiner Address 579 Grand Ave Sarato a S rin s 12866 Death Certificate Filed District Number Register Number City, Town or Village Moreau 4562 / a ©Burial Date Cemetery or Crematory March 1,2017 Pine View Cemetery ❑Entombment Address ❑Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed ZO n Removal and/or Held o and/or Address Hold N O Date Point of NTi Transportation Shipment 'p by Common Destination Carrier Disinterment Date Cemetery Address n Reinterment Date Cemetery Address Permit Issued to Registration Number pi` Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Road,Queensbury, NY 12804 .. Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address .i Permission is hereby granted to dispose of the human remains described above as indicated. } . Date Issued �./gj)I ? Registrar of Vital Statistics 4 '"L 's (signature) >' District Number 4562 Place Moreau I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z 13 W Date of Disposition 6 /7- Place of Disposition 0 �C0,0E.J-z 0.a) l e-e2s2 fi (address) r i cc� J 3 e-. I (s on) _ (lot number) (grave number) p0 Name of Sexton or Person in Charge of Premises i ©,V,J'e L, E D Crz..— (please print) W Signature 04/_1Ui; Va..Q_d__,2_,,,-( Titl (over) DOH-1555(02/2004)