VanGuilder Sr., William NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit/
Vital Records Section * - s
Name First Middle Last Sex
William J. Van Guilder, Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
November 18, 2011 79 War or Dates Yes Korea
j..- Place of Death Hospital, Institution
Z City ,Town or Village City of Albany or Street Address Albany Medical Center
fl` Manner of Death Natural Undetermined Pending
® El Accident ❑ Homicide ❑ Suicide ❑ ❑
wCause Circumstances Investigation
Medical Certifier NILIame Title
p Kevin P. Collins MD
Address
43 New Scotland Ave., Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 2124
Date Cemetery or Crematory
❑ Burial November 21, 2011 Pineview Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
Hold
0 Date Point of
CL Transportation Shipment
Cl) El By Common
CI Carrier Destination
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home Baker-Swan Funeral Home 00121
Address
3256 Riverside Drive,Wellsville, NY 14895
Name of Funeral Firm Making Disposition or to Whom—
Remains are Shipped, If Other than Above
Address
UI
0..; Permission is hereby granted to dispose of the human remains described above s indicated.
i.
Date November 21, 2011
Registrar of Vital Statistics ` ,
Issued (signatur
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:
Z Date of Disposition 1,)0Ut21 201' Place of Disposition 'C,04Va(1") rileturtoriL.-
(address)
lu''i
u)
ce (section) (lot numbe (grave number)
0 S 0 -
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WName of Sexton or Person in Charge of Premises cK`t f 1.04
/►� (please print)
Signature (/, Title CQ€1'+Wl'[81cn
.
(over)
DOH-1555 (02/2004)