DeMars, Jr. Maurice NEW YORK STATE DEPARTMENT OF HEALTH r_
Vital Records Section Burial - Transit Permit
Iii Name First Middle Last Sex
Maurice Arthur DeMars, Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
Miii January 25, 2012 65 War or Dates Yes
Place of Death Hospital, Institution or
City, Town or Village Town of Kingsbury Street Address Aviator Way
CI Manner of Death❑Natural Cause 0 Accident Homicide Suicide ri O Undetermined Pending
l Circumstances Investigation
ill Medical Certifier Name Title
Ruth Scribner Coroner
Address
Death Certificate Filed District Number Register Number
iigiii City, Town or Village January 30, 2012 5762 3
`>OBurial Date Cemetery or Crematory
['Entombment Address
30, 2012 Pine View Crematory, Queensbury, NY
Address
iiiii OCremation
Date Place Removed
❑Removal and/or Held
and/or Address
h Hold
fitj
{3 Date Point of
14`" Transportation Shipment
G" by Common Destination
Carrier
Disinterment Date Cemetery Address
in r:Reinterment Date Cemetery Address
Permit Issued to Registration Number
': Name of Funeral Home Maynard Baker Funeral Home 01130
Address
11 Lafayette Street, Queensbury, NY 12804
igii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IZ
t
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1/31/2012 Registrar of Vital Statistics l TY)444---
(signature)
aii District Number 5762 Place Town of Kingsbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k"' p,,,t i Date of Disposition 2 f i /i L Place of Disposition vat.) Cam,,t+of i o-
(address)
Ili
til
CC (section) = (lot number) (grave number)
i> Name of Sexton or Per n in Charge I►f Premises (. 11'
upk r e�n�>
2 1 (please print)
W.
Signature ,4 l Title Caen P"Co --
(over)
DOH-1555 (02/2004)