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Herrick, Omar # s%c NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section r. , � _ Burial - Transit Permit Name First Middle Last Sex Omar L. Herrick Male Date of Death Age If Veteran of U.S. Armed Forces, 10/02/2013 91 years War or Dates 1 Place of Death Hospital, Institution or 6 City, TgG((rXXr)IXX C Saratoga Springs Street Address Wesley Health Care Center a Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide 0 Undetermined ❑Pending Circumstances Investigation tu Medical Certifier Name Title Susan Sperry N P Address 131 Lawrence Street, Saratoga Springs, Ny Death Certificate Filed District Number Register Number City, TOXIXXrX)CX ( Saratoga Springs 4501 399 ❑Burial Date Cemetery or Crematory ['Entombment Address Pineview Crematorium Address ©Cremation Queensbury N Y Date Place Removed Z n Removal and/or Held and/or Address Hold 0 Date Point of ingi'❑Transportation Shipment Gs by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home 00448 Address 7 Sherman Ave, Corinth, New York 12822 Name of Funeral Firm Making Disposition or to Whom } Remains are Shipped, If Other than Above Address LAI 9' Permission is hereby granted to dispose of the human remain crib d abse as 'ndicate . Date Issued 10/03/20 13 Registrar of Vital Statistics (signature) District Number 4501 Place Saratoga Springs I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI Date of Disposition r0 h(j3 Place of Disposition ,, ,, tr,/ Crrs fir' _. (address) CC (section) lqt number) f^ (grave number) aName of Sexton or Person-in Charge of remises "'1 if r (pie se print) ,„„„,,,! fff Signature Title COCkftrOC (over) DOH-1555 (02/2004)