Humphreys, Theodore NEW YORK STATE DEPARTMENT OF HEALTH Ti 3
Vital Records Section f ` o ' Burial - Transit Permit_
Name First Middle Last Sex
Theodore Ferdinand Humphreys Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/12/2012 83 years War or Dates
F- Place of Death Hospital, Institution or
WCity, M dli- a Saratoga Springs Street Address Wesley Health Care Center
a Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
it/ Circumstances Investigation
tu Medical Certifier Name Title
iy Rick D. Teetz M. D.
Address
131 Lawrence Street, Saratoga Springs N Y
Death Certificate Filed District Number Register Number
: City, li4?i*Male Saratoga Springs 4501 15
❑Burial Date Cemetery or Crematory
01/13/2012 Pine View Crematory
['Entombment Address
❑Cremation Queensbury N Y
Date Place Removed
❑Removal and/or Held
and/or Address
=
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Hold
0 Date Point of
M.a Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
Queensbury, N Y
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
Z Address
CC
tt
P` Permission is hereby granted to dispose of the human remai e ib abo as indicated.
Date Issued 01/12/2012 Registrar of Vital Statistics -4-Eir.tvnA
(signature)
District Number4501 Place Saratoga Springs
" I certify that the remains of the decedent identified above were dispose fin accordance with this permit on:
t.
ill Date of Disposition j j-J t Place of Disposition i"t IL) Cold Drip._
2 (ads)
LU
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CC (section) (lot number) (grave number)
Ct
Name of Sexton or Per •n in Charge of remises . "rts"c � 3to1it
please print)
Signature I/'� _ Title (Q ErniitZ OQ.
(over)
DOH-1555 (02/2004)