Simmons, Guy Jun. 01.2017 02: 10 PM COMPASSIONATE FONEA'i,.. CAR 15185844843 PAGE. 1/ 1
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial . Transit Permit
Name First Middle Last Sex
Guy Douglas Simmona Male
'.A
Date of Death Age If Veteran of U.S. Armed Forces,
05 / 21 / 2017 52 War or Dates N/A
Place of Death Hospital, Institution or
ni City, Town or Village Saratoga Street Address Rte 9P Fitch Rd/Saratoga Lake
a. Manner of Death t—li...j Natural Cause CE Accident n Homicide El Suicide pi Undetermined ri Pending
Circumstances l'-'investigation
1-: Medical Certifier Name Title
Daniel J. Kuhn Coroner
Address
40 McMaster St., Ballaton Spa., NY 120250
Death Certificate Filed District Number Register Number
City,Town or VIllav Saratoga
SIBurial Date ,i. Cemetery or Crematory
U(0/0//c20/7 Park View Cemetery
Entombment Address
N OCremation Schenectady, NY
Date Place Removed
Removal and/or Held and/or
Address
i Hold
Date Point of
Ej Transportation
Shipment
by Common Destination
! !, Carrier
Z 1-1 Disinterment Date Cemetery Address
kiI L.(
gi 0 Reinterment Date 'Cemetery Address
Permit Issued to Registration Number
t Name of Funeral Home Compassionate Funeral Care 00364
Address
11 402 Maple Ave., Saratoga Sp., NY 12866
4. Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
-; Permlaelon is hereby granted to diapose of the human remains described above as indicated.
0 Date Issued 4201/7 Registrar of Vital Statistics VAlliild ,W_COCLE-
(signature)
N
1:4 District Number. 010 5 Place Saratoga , New York
-.., I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition I z/oPlace of Disposition
(address)
Name of Sexton or Person in Charge f Premises •,
.
("ctieni (grave number)
WIrtnumber) r
1 Ans
(pletc(m) . j i'llitt
Signature Zi — • Title CREPOIL
J
(over)
DOH-1555 (02/2004)