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Munoff, Samuel NEW YORK STATE DEPARTMENT OF HEALTH 'Vital Records Section Burial - Transit Permit < . Name First Middle , Last Sex Samuel J. Munoff Male Date of Death Age If Veteran of U.S. Armed Forces, January 28, 2013 92 War or Dates t. Place of Death Hospital, Institution or 111 City, Town or Village Street Address tn Manner of Death 0 Natural Cause 0 Accident piHomicide ❑ Suicide n Undetermined ❑ Pending VI Circumstances Investigation M Medical Certifier Name Title E: : Suzanne Blood, Dr. Address 161 Carey Road Queensbury, NY 12804 Death ficate Filed District Number Rrer Number Cit , Town o Village C g st lc *.n C9 C ❑Buria Date Cemetery or Crematory January 30, 2013 i Pine View ❑Entombment A re s ©Cremation uuasker Road Queensbury,NY 12804 Date Place Removed o ❑ Removal and/or Held Pine View and/or Address E.: Hold Quaker Road Queensbury,NY 12804 Oi Date Point of ug- ❑Transportation Shipment by Common Destination at Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address CC LU C1. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued'I ( SO U Registrar of Vital Statistics Cc„.____ qj CCn A. r ._, (signature) District Number c(.9 c Place 1 Q LA -N ,c CD 112,., I certify that the remains of the decedent identified above were disposed of in acco dan with this permit on: ui Date of Disposition 01/30/2013 Place of Disposition Quaker Road Queensbury,NY 12804 W; (address) CO C (section) ( . (lot number) (grave number) a; Name of Sexton or P rson in Charge of Premises i r! Slnrlrl- (please print) Signature Title ale1 (over) DOH-1555 (02/2004)