Wait, Percy NEW YORK STATE DEPARTMENT OF HEALTH s a Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Percy Maxime Wait Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/30/2014 47 War or Dates No
I- Place of Death Hospital, Institution
Z City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
w Manner of Death Natural
U ® Cause ❑ Accident ❑ Suicide El
Undetermined ❑ Pending
❑ HomicideCircumstances Investigation
III
Medical Certifier Name Title
CI Shazaan F. Hushmendy MD
Address
43 NEW SCOTLAND AVENUE. ALBANY, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 630
Date Cemetery or Crematory
❑ Burial 04/01/2014 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
Hold
0 Date Point of
a Transportation Shipment
Cf) ❑ By Common
6 Carrier Destination
ElDate Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01079
Address
182 Broadway, Fort Edward, NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Ce
O Permission is hereby granted to dispose of the human remains described abo as jndicated/
Date 03/28/2014 Registrar of Vital Statistics �G7lh�"e V / �,�.
Issued (signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this ermit on:
Z Date of Disposition 4 I't y Place of Disposition �t lV"J� (�� �
w addrCss
w
Cl)
re (section) (lot ber) (grave number)
O J
Z Name of Sexton r Person i harge of Premises65t ���
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kt
�!J (please print)
Signatur L '!(/ Title C.,./1-1,0"/;7- 4. k.4--
(over)
DOH-1555 (02/2004)