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Haak, Jr. William TT11 l ti ``ffxx�v5 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex William L. Haak,Jr. Male Date of Death Age If s, of U.S. Armed Forces, October 8,2011 26 •.4 Dates Place of Death He al, Institution or Z City, Town or Village Johnsburg S` at Address 802 S.Johnsburg Road p Manner of Death Natural Cause I XI Accident 1 ' -'imicide Suicide I I Undetermined Pending W - Circumstances Investigation W Medical Certifier Name Title William Orluk Address Chester Health Center,Chestertown,NY 12817 Death Certificate Filed District Number Register Number City, Town or Village Johnsburg 5655 3 ❑Burial Date Cemetery or Crematory Entombment Address 11,2011 Pine View Crematory LI Address ©Cremation Quaker Rd.,Queensbury,NY 12804 Date Place Removed ZO Removal and/or Held and/or Address H Hold O Date Point of NI 'Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00035 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom I—_Remains are Shipped, If Other than Above a Address t>C W G. Permission is hereby granted to dispose of the human re ains��dd/escri d e as indicated. Date Issued lo // dd t( Registrar of Vital Statistics ,—tf � t ip (signature) District Number 5655 Place Johnsburg I certify that the remains of the decedent identified above were disposed of in accordanceor� with this permit on: W Date of Disposition jo llzl it Place of Disposition irinA .tr,t C etwc jto�iv�... (address) W C (section) ` (lot number` (grave number) pName of Sexton or Peron in Charge f PremisesJt„�t u l Ar (please print) Signature Title (Q 'I=(''i A'l; (over) DOH-1555(02/2004)