Hutchins, Herman Jul 06 2015 3:54PM Stuart-Fortune-Keough rn o v a-.37.-7uva ray..
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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - transit Permit
11 Name First Middle Last i Sex
r`" Herman E Hutchinsmale
''-Ti.;
Date of Death Age If Veteran of U S.Armed Forces,
, Jul 1, 2015 84 War or Dates
xr ,
55 Place of Death Hospital, Institution or
11, ,"_ ,Town or Vim Tupper Lake Street Address Mercy Living Center
Manner of Reath L_INatural Cause 0 Accident Q Homicide. E]Suicide ri Undetermined ❑Pending
Tel 1Circumstances investigation
inI Medical C trier Name Title
tsgt Eva Hettena MD
114 W wbeek`Ave Tupper Lake, NY 12986
, { Death Cert'lioate Filed District Number Rogistor Number
1,, C,Town;or Village( Tupper Lake '. 1650 .7a`�
It- D5uriai Date Cemetery or Crematory
Jul 6, 2015 Pine View Crematory
t4 ❑Entorrbmnt Address
._[x C
E'. remation Queensbur NY
Date Pleas Removed
Rtatnov and/or Held
and/or Address
. ; Hold ,
D
[�Transpotate Point of
ation Shipment
by Corn on Destination
:::, Carrier
®Disinterment Date Cemetery Address i14
Reinterment Date Cemetery Address
Permit 1sst.ed to
;fit 3. ;- Registration Number
Name of Funeral Home • Ale.a 1dt er FH 1 000JS
Address
€:1', 3809 Main St. Wary. 'r it, g, NY 12385
; Name of Funeral Firm Making Dispocit. n -�r t)Whom
i`'` Remains are Shipped, If Other than Above
Address
1
Permission Is hereby granted to dispose of the human em described above as d ted.
_'} Date Issued Jul 6 2015 ,,��
<.r? r Registrar of Vital Statistics �°,�' � � ...1'.c-E�C,�/•t�
F,, District.Number 1650 Place Tupper Lake, NY
l I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
`Y,.f Date of Disposition 7/2/cc Place of Disposition Et:0,4 (i-444*(..r
<; (address)
4 (asoticr.) A(lot ns mbar) (grave number)
1 Name of Sexton or Person in Charge of Premises_ !mot St•v,i
( .p rn i
, Signature Title — /141Ptttt
(over)
DOH-1555 (02/2004)