Pugh, Paul NEW YORK STATE DEPARTMENT OF HEALTH
#I1b
Vital Records Section Burial - Transit Permit
Name First Middle'aul E. IFtVh Seale
Datte1of/POeath Aced years If Veteran of U.S.1%ricj orces,
War or Dates
1- Place of Death Hospital, Institution or
Town Of Milton 30 Hine Hollow Drive
W City, Town or Village Street Address
Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined FlPending
UJ Circumstances Investigation
W Medical Certifier Name TEtlis
C1 Howard R. Schlossberg
ANWPfiverview Road, Rexford, Ny 12148
v,9Ig4th Certifi d Milton Dis4�61 umber Re6gister Number
t{�``i, Town o �9e
❑Burial Date03/11/2014 Cervinery or CLremat rv_
ine iew rema o�ryY
0 Entombment Address
`(Cremation ueensbury NY 12804
Date Place Removed
ElRemoval and/or Held
and/or Address
F_- Hold
Cl)
0 Date Point of
0 Transportation Shipment
Q by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
wi Permit Issued to Compassionate Funeral Care Re��t dlion Number
Name of Funeral Home
Addre462 Maple Avenue, Saratoga Springs, Ny 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
ili
a' Permission is hereby granted to dispose of the human rema' s described above a dicated.
03/11/2014 // �
n
Date Issued Registrar of Vital Statistics j'. C e,c..� -- `e-C-
(signature)
District Number 4561 Place Milton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lW Date of Disposition 3-/3 -/V Place of Disposition 6?,iii . (it X--.4-1 ��x%�it1l,7 1-147
(address)
W
Cl)
CC e, (section) (lot number) (grave number)
0 F
p Name of Sexton o/p so . arge of Premises
ili Signature y f x*} / / Title 4%IZ AS 1
(over)
DOH-1555 (02/2004)