Stark, Paul NEW YORK STATE DEPARTMENT OF;HEALTH { r ii tigf
Vital Records Section i _ Burial - Transit Permit
Name First Middle - Last Sex
Paul D. Stark Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/15/2013 85 years War or Dates WWII
Place of Death Hospital, Institution or
iji City, Towuk (ill RXX Glens Falls Street Address Glens Falls Hospital
12 Manner of Death❑N tural Cause ❑Accident ❑Homicide ❑Suicide ri I--'Undetermined ❑Pending
itiCircumstances Investigation
W Medical Certifier Name Title
0 Marvin Davidowitz M D
Address
100 Park St Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, ToWJY )(ill XXX Glens Falls 5601 355
❑Burial Date Cemetery or Crematory
['Entombment Pine View Crematorium
Address
;;;;❑Comation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
i ❑and/or
Address
H Hold
CD
Date Point of
ti El Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to �`/ Registration Nu er
Name of Funeral Home h f�SO0 f oN�n2 nt CI�n�Z • �(
Address i S+ f`fr AK /i , It Z1,
slot ! `_'
Name of Funeral Firm Making position or to Whom
14 Remains are Shipped, If Other than Above
Address
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` Permission is hereby granted to dispose of the human remains described above as indicated.
Iii Date Issued 08/16/2013 Registrar of Vital Statistics IA.)c k 4-v.¢- VU�A.`
(signet re)
District Number 5('i01 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W. Date of Disposition g/ZO!3 Place of Disposition 'IAiv L ovivtat -
2. (address)
Lu
to
CC (section) (lot number) c (grave number)
ti Name of Sexton or Person in Charge of Premises A:: `-'Pla
2 (ple se print)
lliSignature 41,—. /� Title Clleilli (over)
DOH-1555 (02/2004)