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Shattuck Sr., Wilbur NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit omit Vital Records Section ni Name First Middle Last Sex WILBUR F SHATTUCK SR MALE Date of Death Age If Veteran of U.S.Armed Forces, 02/08/2017 81 War or Dates F- Place of Death Hospital, Institution Z City, Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER W Manner of Death Natural ❑U.I Cause ® Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation ui Medical Certifier Name Title Q MICHAEL SIKIRICA MD Address 112 STATE ST., ALBANY NY 12207 Death Certificate Filed District Number Register Number City,Town or Village City of Albany 101 337 Date Cemetery or Crematory ❑ Burial 02/10/2017 PINEVIEW CREMATORY ❑ Entombment Address ® Cremation QUEENSBURY, NY Date Place Removed Z ❑ Removal and/or Held and/or Address H Hold ) d, Transportation Date Point of y)' ❑ By Common Shipment a'' Carrier Destination El Disinterment Date Cemetery Address ❑ Date Cemetery Address Reinterment a Permit Issued To Registration Number Name of Funeral Home BREWER FH INC 00211 Address 24 CHURCH ST LAKE LUZERNE NY 12846 Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped, If Other than Above E Address tli ©- Permission is hereby granted to dispose of the human remains descri d bov Indic d. Date 02/10/2017 Issued Registrar of Vital Statistics ‘ 4�g ' � (sig "t re) 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: WH Date of Disposition z ij/n Disposition ' 0,-1 (c'do i p �( Place of t,,.,, LU (address) w co 0 (section) (lot number) (grave number) Ci '' 2 Name of Sexton or Person in Charge of Premises /hry S'",Olt W (please print) I. Signature 4.) Title fgE OW (over) DOH-1555 (02/2004)