Water, George NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit 'P`ermit
Vital Records Section
Name First Middle Last Sex
GEORGE WAGER MALE
Date of Death Age If Veteran of U.S.Armed Forces,
03/06/2017 76 War or Dates 1957-60
I--- Place of Death Hospital, Institution
Z City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
QManner of Death ® Natural ❑ Undetermined ❑ Pending
W'_ Cause Accident Homicide Suicide
Circumstances Investigati
❑ ❑ ❑ on
WMedical Certifier Name Title
p MARY MASKELL-AMIRAULT NP
Address
43 NEW SCOTLAND AVE., ALBANY NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 540
Date Cemetery or Crematory
❑ Burial 03/08/2017 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
N Hold
Cl)
Date Point of
C. Transportation Shipment
CO ❑ By Common a Carrier Destination
0 Date Cemetery Address
Disinterment
0 Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home MILLER FH 01199
Address
6357 NYS RTE 30 PO BOX 718 INDIAN LAKE NY 12842
FName of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
*' Address
Cd
W"
a° Permission is hereby granted to dispose of the human remains descri ab as ind t % ft
-
Date 03/08/2017 y* i *AL
Issued Registrar of Vital Statistics ' i
(sign ture
District Number 101 Place City of Albany, NY ,—.'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition �I ,,I7 Place of Disposition 'f�ntOs'w ift mQ�Of)' '
ILI (address)
2
U)
W' (section) (lot number) (grave number)
0 Z Name of Sexton or Person in Charge of Premises I f rij+, df' 1�ittr
w (please print) //
Signature g fr Title /4 NI94_
(over)
DOH-1555 (02/2004)