Auer, Jack 4 Z33
NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jack H Auer Male
::' Date of Death j Age ' If Veteran of U.S. Armed Forces,
May 1, 2011 79 , War or Dates
. Place of Death Hospital, Institution or
City, Town or Village Albany Street Address Albany Medical Center
tit
Manner of Death I Natural Cause X Accident n Homicide Suicide Undetermined Pending
IS; Circumstances Investigation
tis° Medical Certifier Name Title
g, Herman Thomas Coroner
Address
112 State Street,Albany,NY
„;= Death Certificate Filed ! District Number Register Number
City, Town or Village Albany 10 I %"-a I
❑Burial Date Cemetery or Crematory
May 4, 2011 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date 1 Place Removed
Z Removal 1 ; and/or Held
and/or 1Address
H Hold
0 I Date Point of
a.
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
s. Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01464
Address
53 Quaker Road, Queensbury, NY 12804
;a Name of Funeral Firm Making Disposition or to Whom
kiiii, Remains are Shipped, If Other than Above
, ° Address
IX,
tit
PA
Permission is hereby granted to dispose of the hu n remains described ab.ve as indicated.
Date Issued S) a I i j Registrar of Vital Statistics w .
(si.nature) 0.
District Number Place Alban '
JDI y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 5-t. i( Place of Disposition Pt nt V,t w L f Vin.C{o i'iun.
2 (address)
W
Cl) •re (section) { (lot numl�r (grave number)
QName of Sexton or rson in Charg of Premises ! 1iis- is Jponit-
Z (please print)
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SignatureTitle Ci" Eirp,iC�
11:1_,
(over)
DOH-1555(02/2004)