Walraven, Ervin NEW YORK STATE DEPARTMENT OF HEALTH . ' # GTO
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ervin Eugene ` Walraven Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 23, 2014 80 War or Dates Yes 1956-1973
1- Place of Death Hospital, Institution or
City, Town or Village Albany Street Address St. Peter's Hospital
0 Manner of Death,Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined El Pending
VCircumstances Investigation
W Medical Certifier Name Title
CI Michael Perrotti MD
Address
319 S. Manning Blvd. , Albany, NY 12208
Death Certificate Filed Albany District Number 101 Register Number
City, Town or Village 1999
0 Burial Date Cemetery or Crematory
October 28, 2014 Pine View Crematory
;;;❑Entombment Address
<' ®Cremation Queensbury, NY
Date Place Removed
l ❑Removal and/or Held
and/or
, Address�
Hold
IA
O Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Wilcox &
Name of Funeral HomeRegan01821
Address
11 Algonkin Street, Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
1, Remains are Shipped, If Other than Above
;; Address
L
Permission is hereby granted to dispose of the human remain described above as" dica
Oct. 24, 2014 g c
Date Issued Re istrar of Vital Statistics F4)
(signatur
District Number 101 Place City of Albany
I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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ILI Date of Disposition (0(ap(i'( Place of Disposition -E-40,..1 (rw{sr
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0
ix (section) (loottt umber) C (grave number)
Name of Sexton or Person in Charge of Premises G�r��f J�
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Signature FL Title «�"
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DOH-1555 (02/2004)