Holland, Samuel , lk. i'1 3
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Samuel B. Holland Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/111:011 71 years War or Dates
Place of Death Hospital, Institution or
• City, ToX`wVi19x_ caratnga {, rings Street Address Sr
aat„ Hospital
O Manner of Death❑Natural Cause 0 Accident ❑Homicide ❑Suicide Li Undetermined ❑Pending
illCircumstances Investigation
w Medical Certifier Name Title
Q Thomas A_Saivaclore Saratoga County Coroner
Address
41 South Main Street, Mechanicville, N Y 12118
Death Certificate Filed District Number Register Number
City, Toiym l itX Saratnga Springs 45t11 12
❑Burial Date Cemetery or Crematory
❑Entombment 01/'I?/7011 Pineview Crematorium
Address •
lPremation Oueensbury N Y
Date Place Removed
.. Z ❑Removal and/or Held
and/or Address
-, Hold
CO
O Date Point of
CL
❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00442
Address
7 Sherman Ave. Corinth. New York 12822
Name of Funeral Firm Making Disposition or to Whom
# * Remains are Shipped, If Other than Above
Z Address
IX
141
Permission is hereby granted to dispose of the human remain cribed above as indicated.
Date Issued 01/13/2011 Registrar of Vital Statistics trevN "1- lutaibuit
(signature)
District Number Place
4501 Saratoga Springs
#-
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
1. Date of Disposition Tc,lea i`I) Place of Disposition lou 4ew Cs torod.—
(address)
LU
CC (section) (lot num (grave number)
• Name of Sexton or Person in Chargey Premises .� ber,r,c�ielN"f- .,..ill`
zr. (please pnnt)
ILI Signature - Title Cat:: On iq-i(1i
(over)
DOH-1555 (02/2004)