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Detmer, M. Samuel * 0.13 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex M.Samuel Detmer Male Date of Death Age If Veteran of U.S.Armed Forces, 09/28/2020 62 Years War or Dates Place of Death Hospital,Institution or z City,Town or Village Moreau Town Street Address 1657 Route 9,Moreau Town, New York 12803 Manner of Death Undetermined Pending W ©Natural Cause Accident Homicide Suicide Circumstances Investigation W Medical Certifier Name Title Anthony Petracca MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 39 ❑Burial Date Cemetery,Crematory or Facility Name 10/01/2020 Pine View Crematory ❑Entombment Address lCremation Queensbury Town,New York ❑Donation Z Removal Date Place Removed and/or and/or Held N Hold Address 1-1�- Date Point of Cl) ❑Transportation 5 by Common Shipment Carrier Destination 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom . Remains are Shipped,If Other than Above I Address NJ O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/01/2020 Registrar of Vital Statistics Leeann Mc cabe(E(ectronicatty Signed) (signature) District Number 4562 Place Moreau, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z tU Date of Disposition ](fit Z]/0 Place of Disposition t�✓ r—� 2 (address) W N (section) (lot num (grave number) 0 Name of Sexton or Person in Charge of P ises / ;tpL �- 1•6��� (please print) W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of • delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#