Kaplan, James RX Date/Time 07/10/2017 11:52 15-"'5844843 P.001
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Ju1. 10.2017 01:12 PM COMPASSIONATE FUNERAL 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
V acmes M. Kaplan Male
Date of Death Age If Veteran of U.S. Armed Forces,
07 / 06 / 2017
69 War or Dates Air Force
Place of Death Hospital, Institution or
1 City, Town or Village Street Address Route 32 & Lohnea Road _
5 Manner of Death Lil—I Natural Cause El Accident 0 Homicide l=I Suicide 0 Undetermined ri Pending
11 Circumstances 'Investigation
gi Medical Certifier Name Title
Michael sikirica MD
Address
50 Broad St, Waterford, NY 12188
Death Certificate Filed District Number Register Number
N City, Town or Village
Ell Burial Date Cemetery or Crematory
git 07 / 10 / 2017 Pine View Crematory
ROEntombment Address
k!!k PIC ti rema on Queensbury, NY
;!g Date Place Removed
ri Removal
I-4 and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination and/or Held
El
1 Carrier
A r•-i Disinterment Date Cemetery Address
n u
W-...-Reinterment Date Cemetery Address
4,...,
At u
Y 0.
)i•P Permit Issued to Registration Number
1 Name of Funeral Home Compassionate Funeral Care 00364
Air Address
r 402 Maple Ave., Saratoga 6p., NY 12866
41
•.$ Name of Funeral Firm Making Disposition or to Whom •
Remains are Shmed, If Other than Above
Address
Permission le hereby granted to dispose of the human remains described above as indicated.
4 Date Issued 71101201 Registrar of Vital Statistics LL440,7-A-MS‘,18.4,_
(signature)
0: District Number 4+5(6,5 Place -Then 041 54al.r10... , NOW York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1 111 i ti Place of Disposition
Name of Sexton or Person in Charge of Pre ises .(.5"tien)
. U.,vi,) ert,...et o("fr..
(address)
,
. ot number) -to41 it ;g-rave number)
ibitf-
(pleas*print)•
Tii Signature .10 Title 4REMh14
(over)
DOH-1555 (02/2004)