Williams, Eugene t w
NEW YORK STATE DEPARTMENT OF HEALTH 4 I
,:
Vital Records Section Burial - Transit Per it
Name First Middle Last ' Sex
Eugene L. . Williams Male
Date of Death Age If Veteran of U.S. Armed Forces,
06 / 06 / 2017 84 ' War or Dates N/A
-- Place of Death Hospital, Institution or Washington Ctr. for Rehab. &
Z City, Town or Village Argyle Street Address Healthcare, 4573 NY-40
QManner of Death®Natural Cause E Accident 0 Homicide D Suicide 7 Undetermined �Pending
W. Circumstances Investigation
111 Medical Certifier Name Title
Edit R. Masaba MD
Address
200 Main St, Greenwich, NY 12834
: Death Certificate Filed District Number S 7 SD RegisterNumber
City,Town or Village Argyle
€< 0Burial Date Cemetery or Crematory
06 / 06 / 2017 Pine View Crematory
'''< fEntombment Address
17Cremation Queensbury, NY
Date Place Removed
1❑Removal and/or Held
and/or Address
Hold
`fit
Date Point of
Q Transportation Shipment
{ by Common Destination
Carrier
iiiiii
❑Disinterment Date Cemetery Address
iiiIiii!Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
i Address
402 Maple Ave., Saratoga Sp., NY 12866
<`< Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
it
Ui
Permission is hereby granted to dispose of the human remains described above as indicated.
iiiiig Date Issued (pi(, al Registrar of Vital Statistics c' _9 '4a ,. kw�cn
(signature)
iii
Mill District Number 5150 Place Argyle , New York
#-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 r'
l Date of Disposition ( 18717 Place of Disposition f e(eLI a,f'or .-
al (address)
to
(section) lot number) (grave number)
(14 c
il3 Name of Sexton or Person in Charge of Premises & t- ShtiU-
at (pie print) •
tr Signature t'1jr__, Title Ca'f /h 10/t-
(over)
DOH-1555 (02/2004)