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Dubois, Patrick NEW YORK STATE DEPARTMENT OF HEALTI-r b tr Z9") Vital Records Section Burial - Transit Permit <r Name First Middle Last Sex Patrick J. Dubois Male f,' Date of Death Age If Veteran of U.S. Armed Forces, 'f �% June 1, 2012 76 War or Dates 1 ❑X�' Place of Death Hospital, Institution or City, Town or Village Saratoga Springs Street Address Saratoga Hospital Manner of Death Natural Cause ❑Accident El ❑Suicide n Undetermined n Pending . Circumstances Investigation Medical Certifier Name Title Timothy Brooks,MD .: Address -£== Saratoga Springs,NY =fib Death Certificate Filed District Number ////�Z Register Number r City, Town or Village Saratoga,NY T / a,�g ❑Burial Date Cemetery or Crematory ❑Entombment June 6, 2012 Pine View Crematory Address ©Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed ZZ ❑Removal and/or Held and/or Address i' Hold tn 0 Date Point of N ❑Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Renterment Date Cemetery Address `" Permit Issued to Registration Number ' Name of Funeral Home Regan & Denny Stafford Funeral Home 01443 F Address '' 53 Quaker Road,Queensbury,NY 12804 Name of Funeral Firm Making Disposition or to Whom : Remains are Shipped, If Other than Above Address - Permission is he eb granted to dispose of the human rema' e rind ab� indicate . r Date Issued 0 Registrar of Vital Statistics J-„;, (signature) District NumberD/ Place Saratoga,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: LuDate of Disposition &11 i IZ Place of Disposition &Oi,,,, Crel,f0r,o,. 2 (address) cola ce (section) - (lot number)(^ (grave number) pName of Sexton or Person in Charge of remises (i„A- r chests W (please print) Signature 1 Title CIF Mri1T0C (over) DOH-1555(02/2004)