Amara, Paul NEW YORK STATE DEPARTMENT OF HEALTH + `3
Vital Records Section Burial - Transit Per it
Name First Middle Last Sex
Paul Girard Amara Male
Date of Death 1 1 /1 9/2 01 8 Age 76 If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Glens Falls Hospital, Institution or Glens Falls Hospital
City, Town or Village Street Address
Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide x❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name r f Ai P {Sc„ko Title µ0
Address 1 �(�� U
100 Park Street, Glens Falls, NY
Death Certificate Filed District Number ���) Register Number 5c/�
City, Town or Village Glens Falls
❑Burial Date 1 1 /21 /201 8 Cemetery or Crematory Pine View Crematory
❑Entombment Address
cremation Quaker Road, Queensbury, NY
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the human remains desjorib d ov s i ed.
Date Issued ii 2%2&lr Registrar of Vital Statistics yti,
(signature)
District Number 5 0/ Place l A 74 A �
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition II(Zi IIQ Place of Disposition ��U.,,,, [Ladr�.
(address)'
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises �rs. S t nn 4if
(pltase print)
Signature Title (i?tm 0,2,
(over)
DOH-1555 (02/2004)