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Sebald, Danald NEW YORK STATE DEPARTMENT OF HEALTH t Vital Records Section Burial - Transit Permit Name First Middle Last Sex .. Donald J.Sebald Male - Date of Death Age If Veteran of U.S. Armed Forces, 12/22/2017 79 Years War or Dates - Place of Death Hospital, Institution or City, Town or Village Queensbury Town Street Address Westmount Health Facility - Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide 1-1 Undetermined ❑Pending Circumstances Investigation • Medical Certifier Name Title Roslyn Socolof MD - Address 42 Gurney Ln,Queensbury Town,New York 12804 ,; Death Certificate Filed District Number Register Number . City, Town or Village Queensbury 5657 163 ❑Burial Date Cemetery or Crematory 12/26/2017 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of •❑Transportation Shipment by Common Destination Carrier Iy- Date Cemetery Address 0 Disinterment - Date Cemetery Address - ❑Reinterment Permit Issued to Registration Number ;; Name of Funeral Home Brewer Funeral Home Inc 00211 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 12/26/2017 Registrar of Vital Statistics CarolineMBar6er Electronically Signed (signature) District Number 5657 Place Queensbury, New York IT I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ' - Date of Disposition j2/z?/j7 Place of Disposition Pih - L i ' G re 'l1.4/1 I / (address) (section) (lot number) (grave number) - Name of Sexton or Person in Charge of Premises —It, I ' ``n 6 �c-�- (pleasprint) /,� Signature J ' k. Title L �-P rritA / ,' (over) DOH-1555 (02/2004)