Fayette, Norman #13g z
NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Norman George Fayette Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/13/2014 it.JD-years War or Dates
f+- Place of Death Hospital, Institution or
Z City, TowXXX 'iI XX Glens Falls Street Address Glens Falls Hospital
0 Manner of Death❑aatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
LEI Circumstances Investigation
W Medical Certifier Name Title
12 Mark Hoffman M. D. —
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, TowXXXX/iDXX Glens Falls 5601 281
❑Burial Date Cemetery or Crematory
06/18/2014 Pine View Crematorium
['Entombment Address
❑Cremation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
..�. and/or Address
H Hold
CA
0 ' Date Point of
N❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home rtc Kzt-li4g r tit,
Address
VVL Mild sr 9,414 U04A- OW Pi - 1i 3 .
Name of Funeral Firm Making Disposition or to Whom
#- Remains are Shipped, If Other than Above
2 Address
Ui
13` Permission is hereby granted to dispose of the human remains described above as indicated.
•
Date Issued 06/17/2014 Registrar of Vital Statistics k-) o - ik) t^(signa re)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed off in accordance with this permit on:
U Date of Disposition L (Ig/N Place of Disposition _ 'Ct tt-i at-- a7v---
(address)
it
La
(section) (lot number) (grave number)
CI Name of Sexton or Person in harge of Pr mises �.•1 .' J
(pse print)
Signaturewett
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(over)
DOH-1555 (02/2004)