Stevens, William -, o- till
NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
Name First Middle Last Sex
William R. Stevens Female
Date of Death Age If Veteran of U.S. Armed Forces,
11 / 06 / 2017 78 War or Dates N/A
}- Place of Death Hospital, Institution or
Z City, Town or Village Northumberland Street Address 10 San Luis Road
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0 Manner of Death®Natural Cause 0 Accident 0 Homicide Suicide ❑Undetermined 7 Pending
Circumstances Investigation
ill Medical Certifier Name Title
0. Christopher T. Messitt MD
Address
135 N Rd, Wilton, NY 12831
''! Death Certificate Filed District Number Register Number
City, Town or Village Northumberland �2 ` I
•
°Burial Date Cemetery or Crematory
11 / 08 / 2017 Pine View Crematory
; `8 Entombment4 en Address
Ri Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
CZ Hold
Date Point of •
0 Transportation Shipment
a by Common Destination
Carrier
M]i []Disinterment Date Cemetery Address
iMi
Date Cemetery Address
u::i 0 Reinterment
::.
[< Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
iigii 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
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Permission is hereby granted to dispose of the human mains described above as indicated.
IN
> Date Issued IIV} �Q fl Registrar of Vital Statistics •
( natu )
District Number 1--\a,,3 Place Northumberland , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition II i `1)f Place of Disposition - guilt," (.).-4.,
(ad ress)
MI
CC (section) l (lot number) (grave number)
0 Name of Sexton or Person ip Charge of Pre ises [ SIAAIr
Z /,� /ease punt) •
it Signature di
Title (Merit 11±0—
•
(over)
DOH-1555 (02/2004)