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Rabine, Wayne NEW YORK STATE DEPARTMENT OF HEALTH . � 7 Vital Records Section 1 .. - , Burial - Transit Permit Name First Middle Last Sex Wayne Michael Rabine Male Date of Death Age If Veteran of U.S. Armed Forces, October 27, 2017 55 War or Dates �.. Place of Death Hospital, Institution or wCity, Town or Village Fort Edward Street Address 18 Center Street Manner of Death �Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑Circumstances Undetermined ❑ Investigation Pending Medical Certifier Name Title Max Crossman, M.D. Dr. Address 65 Poultney Steet Whitehall, NY 12887 Death Certificate Filed District Number Register Number City, Town or Village Fort Edward 5r0 Li ❑Burial Date Cemetery or Crematory October 30, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address Hold Date Point of a. ❑Transportation Shipment by Common Destination O Carrier Date Cemetery Address El Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above IAddress • Permission is hereby ranted to dispose of the human re ins describ d ab ve s 'ndicated. Date Issued Registrar of Vital Statistics (.spa, V . � ch (signature) District Number 555 Place / Mt 61-6 in_ �C/ JJG2(.O' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI Date of Disposition 10/30/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) I (section) i�(lot number) f (grave number) a Name of Sexton or Person in Charge of Pre .ses l (r,si i` 3 emit (pie se print) Signature /1 Title (il live- (over) DOH-1555 (02/2004)