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Monroe, Burton Dh• NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit 2 Name First I. Last Sex Burton Ray Monroe ,Tt Male Date of Death Age . Veteran of U.S. Armed Forces, ,' 07/16/2018 77 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls ' Street Address Glens Falls Hospital Manner of Death©Natural Cause El Accident 0 Homicide El Suicide El Undetermined ri Pending Circumstances Investigation T Medical Certifier Name Title Wendy Steinhacker PA Address 100 Park St,Glens Falls,New York 12801 • Death Certificate Filed • District Number Register Number City, Town or Village Glens Falls 5601 350 0 Burial Date Cemetery or Crematory 07/20/2018 Pine View Crematory ▪ ❑Entombmentfi Address ®Cremation Queensbury Town, New York Date Place Removed • Removal and/or and/or Held Address Hold N Date Point of • ❑Transportation Shipment by Common Destination 40 Carrier _ Disinterment Date Cemetery Address El Reinterment Date Cemetery Address kk Permit Issued to Registration Number kg Name of Funeral Home Maynard D Baker Funeral Home 01130 iiv Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address iki Permission is hereby granted to dispose of the human remains described above as indicated. 1 Date Issued 07/17/2018 Registrar of Vital Statistics Rp6ert f Curtis(ECectronfcalty Signed) (signature) District Number 5601 Place Glens Falls, New York X- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: • Date of Disposition Place of Disposition i iim vh, ' Grtakt 4c r y (address) oft- (section)_ (lot number) (grave number) Yam. V T Name of Sexton or Person in Charge of Premises aM'—y i rs.,S (please print) Signature Title C feM►Al10( (over) DOH-1555 (02/2004)