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Ulrich, Augusta 4- t /I 11 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit _. Name First Middle Last Sex a Au usta r. TJT,RIC-I Femal Date of-Death Age If Veteran of U.S. Armed Forces, ,Airo 1 _9 6_7 n 1 R 9 2 War or Dates no Place of Death Hospital, Institution or "'" City, Town or Village Street Address 694 CountyRte. 1 0 � Y� 9 694 Corinth Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide El❑ Undetermined ❑Pending `` Circumstances Investigation • Medical Certifier N e Title timy Johrn5b,1 RP4 c_ w drest / 3 t.ty.n. Alit.. COr,r,fg Aq 1Zg22-- _ Death Certificate Filed District Number R ister Number City, Town or Village Corinth L45 3 _ Lf • ❑Burial Date Cemetery or Crematory ❑Entombment 1 /29/201 8 Pine View Crematory Address ®Cremation Queensbury, NY Date Place Removed '❑ _Removal and/or Held and/or Address t Hold Date Point of ❑Transportation Shipment , by Common Destination Carrier i❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home, Inc. 00211 Address 24 Church St. , Lake Luzerne, NY 12846 1r,ii. Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ,- Address Permission is hereby granted to dispose of the human remai ibed abo as indicated. nA Date Issued /laf X5/8 Registrar of Vital Statistics (signature) District Number itsr3.3 Place 7"0---L,....„ oir )6,11/471-4_. ,,0 . I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition I,i 3E,h Place of Disposition ,,zk:., /,.Li._.., -, (address) (section) d jlot number)c- (grave number) • Name of Sexton or Person in Charge of Premises J i iit1 . ( lease print) zti Signature /" Title (R(MillOg, (over) DOH-1555 (02/2004)