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Sioul Jr., Gaston �fJU NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit - Name First Middle Last Sex Gaston J Sloul Jr Male - Date of Death Age If Veteran of U.S. Armed Forces, 12/11/2017 69 Years War or Dates Viet Nam Place of Death Hospital, Institution or City, Town or Village Albany Street Address Albany Medical Center Hospital Manner of Death©Natural Cause 0 Accident 0 Homicide ID Suicide El Undetermined �Pending Circumstances Investigation Medical Certifier Name Title ffM`= Benjamin Szewczyk MD Address 43 New Scotland Ave,Albany, New York 12208 Death Certificate Filed ( District Number Register Number City, Town or Village Albany 101P' 2730 El Burial Date ietery or Crematory 12/15/2017 a View Crematory []Entombment Address 4 i= ®Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held yr and/or Address Hold Date Point of Q Transportation Shipment by Common Destination Carrier 0 Disinterment Date Cemetery Address 0 Reinterment Date Cemetery Address Permit Issued to Registration Number - Name of Funeral Home Brewer Funeral Home Inc 00211 Est` Address 24 Church Street PO Box 500,Lake Luzerne, New York 12846 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/12/2017 Registrar of Vital Statistics Danieaesciaspie EYectronicafySigned' (signature) District Number 0101 Place Albany, New York or I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: - Date of Disposition It l tr I ti Place of Disposition {?„.14 (address) (section) (lot number) ( (grave number) Name of Sexton or Person in Charge of Premises (please print) Signature Title CO too V, (over) DOH-1555 (02/2004)