Augusta Jr, Samuel NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
IIGp Name First Middle Last Sex
_ Samuel M. Augusta,Jr. Male
t_ Date of Death Age - If Veteran of U.S. Armed Forces,
November 30,2016 80 War or Dates
Y Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
14
t Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
14 Circumstances Investigation
: ° Medical Certifier Name Title
ct Amy Hogan MD
:„: Address
Two Broad Street,Glens Falls,NY 12801
:b Death Certificate Filed District Number Register�Number
`1
City, Town or Village Glens Falls 5601 ' , 7
❑Burial Date Cemetery or Crematory
❑Entombment December 2,2016 Pine View Crematory
Address
El Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
F" Hold
co
0 Date Point of
co Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
`:',: Permit Issued to Registration Number
a.
; Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
,1-„ Remains are Shipped, If Other than Above
a; Address
1kt:
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued C Z j 7.12c W 1� Registrar of Vital Statistics t:L9p ,v, W
(signature
District Number
5 6 0 i Place City of Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z I,, //
ui Date of Disposition IZ(S Ii6 Place of Disposition 7n(vtl,.." `IXmt ut"
W (address)
co
0 (section) ,c/ (lot number) ( (grave number)
p Name of Sexton or Person in Charge of Pre ises t(j.� f 3c^iltr
Z p r!((pl ase print)
la Signaturelrt Title j111_
(over)
DOH-1555 (02/2004)