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NEW YORK STATE DEPARTMENT OF HEALTH � � � Transit Permit
Vital Records Section .
Name Firs Middle B Lorthgard Sex Mafe
First_
Date of Death Age If Veteran of U.S. Armed Forces,
04/26/2016 82 years War or Dates 1952-1958
Place of Death Hospital, Institution or
Town of Amsterdam Street Address Capstone Center Nursing & Rehab
City. Town or Village --
a Manner of DeathLLI Undetermined 0 Pending
aturai Cause Accident Homlclde n Suaclde Circumstances Investigation
0.----,------------Certifier Name Title
P. Hafeez Rehman M D
Adr 8 Riverfront Center, Amsterdam, N Y 12010
Death Certificate Filed 1 District Number I I Register Number
X own or V%KW Amsterdam , 2850
1 Date Cemetery or Crematory
��urial 04/28/2016 Pine View Crematorium
D Entombment Address
;;;; l_ Cremation Queensbury, New York
Date Place removed
❑Removal and/or Held —
and/or Address
It Hold
0 Date
Point of
0 Transportation Shipment
0 by Common Destination
Carrier
El Disinterment
Date Cemetery Address
IIIiII Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral HomeReganDenny Denn Stafford Funeral Home 01443
Address
53 Quaker Rd., Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
it
1
W. Dated.
Permission is hereby granted to dispose of the humanrains described bove
Date Issued 04/28/2015 Registrar of Vital Statistics
District Number 2850 Place Amsterdam
certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
E
tit Date of Disposition 3/3I/b Place of Disposition eet U✓ (address)
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w
ft (section) r(lPt ra p1y a (grave number)
it
ill
Ci Name of Sexton or Person in Charge o Premises
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;;,;. Signature
(.� Title C "i"i '
s;; (over)
DOH-1555 (02/2004)