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Naatz, Floyd Mar 28 2013 8:02AM Brewer Miller Funeral 518-696-2743 page 4 # 1 1i NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit :A Namejrto, _ Middle Q Last x � --- 14, Date of Death I Age {{ If Vetaran of .S. Armed Forces, RI 3--.� c20/3 ( war or Dates/1-6—i t4(o Place of Death Hospital. institutio or Town or ViltagQ _- X c.AD -off /h��- Street Address .� t 4— .-- Manner of Deat0 Natural Cause OA identup Homicide []Suicide Undetermined U Pending Circumstances Investigation -, Medical Certifier Name Title .. tONi'I "1Z1.4 9 Address 341 P114 beta I T ''I''' Death Certifiicate Filed Dis ai Num 7-Register Number $9 4)4,4_,Le i Town or Village e� `t S6 J I . I 'I 7 ? Date Cemetery or/Crams y .-,-.❑Burial �} j -OI3 /"11t� I�t Addre f iv, CremationI LC/ra .y l,.L.,,,�_ Date Removed ZQ Removal i and/or Held and/or Address ..- Hold 1 2 I Date 1 Point of , NQTransportation _ , Shipment ^©I by Common Destination Carrier j _ 0 Disinterment Date I Cemetery Address a Reinterment Date I Cemetery Address 1 I`' Permit Issued to i Registration Number 1 ig Name of Funeral Home �- r��� 5-4 .� i r Address a ( ''Ytj i,,::? egt/(,, 11 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, It Other than Above Address _ Permission ie reby 0ranted to dispose of the human remains abov as i (floated. Date Issued 3 .Z`�/1 Registrar of Vital Statistics r otl (signature) �4 District Number Li S CAI Place SARATOGA SPRINGS I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1N i Date of Disposition •/9-43 Place of Disposition Zelt4t+) l r"wc{ix suN.. (address) OA (section) /,lot number) (grave number) Q Name of Sexton or Person " Charge of Premises (ht,S`I( 9e Q (please print) W Signature %. A Title /'+ Al Azov., DOH-1555 (10/89) p. 1 of 2 VS-61