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Stevens, William NEW YORK STATE DEPARTMENT OF HEALTH Z© Vital Records Section Burial - Transit Permit4.00244 Name First Middle Last Sex WILLIAM STEVENS MALE Date of Death Age If Veteran of U.S. Armed Forces, 01/11/11 37 War or Dates t-- Place of Death Hospital, Institution or 2 City, Towner-Vo i(laae NORTH ELBA Street Address til 18 DOCWOOD WAY Ct Manner of Death ©Natural Cause Accident 0 Homicide 0 Suicide Undetermined 7 Pending WW Circumstances Investigation Medical Certifier Name Title KELLIE M. VALENTINE CORONER Address 1800 ENSIGN POND ROAD MORIAH CENTER, NY 12961 Death Certificate Filed District Number Register Number - 4ty, Town 4f-Village NORTH ELBA 1560 El Burial Date Cemetery or Crematory Entombment 01/18/11 PINE VIEW CREMATION Address ®Cremation GLENS FALLS,. NY Date Place Removed Z Removal and/or Held 3❑ N and/or Address Hold to 0 Date Point of tlm Q Transportation Shipment O by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral H&mg CLARK, INC. 01064 Address 2310 SARANAC AVE. , LAKE PLACID, NY Name of Funeral Firm Making Disposition or to Whom 1* Remains are Shipped, If Other than Above ,Z Address CC 11 Permission is hereby granted to dispose of the Human rem ' s described above as indicated. Date Issued (signature 01/13/1 1 Registrar of Vital Statistics 6,:,/,4....4( (,.,,: ;(,,,,Z..)Aff/ )' District Number 1 960 Place LAKE PLACID (NORTH ELBA) , NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI z; ,� ) C, Date of Disposition 30) Fit ZOIf Place of Disposition -t'►ot( ILL/ - .c1 a' , i (address) U) (section) J (lot number (grave number) CI Name of Sexton or P n in Charg 'f Premises r,y� ��,- n,,,�} ii __ (please print) l Signature r I� 9 Title C Q. T()f'l. (over) DOH-1555 (02/2004)