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Hatin, David i NEW YORK STATE DEPARTMENT OF HEALTH il Burial - Transit li e mi Vital Records Section t -->< Name First Middle tt Si ,ex �q U d it/626•J /?fh/n1 /vete,- Date of Death / Age If Veteran of U.S.Armed Forces, _ 7`3/ Z3 2e War or Dates / 9,rr- /9,s-9 Plac- v ',-ath ,I-aspitai in titution or �I C. Town • Village �D►t Street Addr 3 9/ L L r/P G/4'o-rbL��T -of Man • Death Natural Cause Accident Homicide Suicide Undetermined ❑Pending Circumstances Investigation Medical Certifier Name /�/ , / Title Address /02 / Oi k 7C11/:196:11- CL&r,.� rocs - Death ate Filed ,(� District Number Register mber City owns Village ,/7d gli Burial Date /' 3 Cemetery o Crematory J : _ ['Entombment // / (� LJ b Address / , 'R F.Cremation Q u Ai664-�. i J,NS L UvL- /V Date / Pace Removed / ' Removal and/or Held . t and/or Address Hold 47 Date Point of si 0 Transportation Shipment by Common Destination riA Carrier El Disinterment Date Cemetery Address ii - Q Reinterment Date Cemetery Address M. Permit Issued to Registration Number Name of Funeral Home Hal ncJd "D•?:)Qker Funera( H()n--C 01 110 al Address 11. La4ctye+4e Street Queensbury ► New) y©r- 1< t2i goy i Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above • Address t til ;" Permission is hereby granted to dispose of the human remai s described abov as indicated. Op Date Issued 8/'L//,5. Registrar of Vital Statistics ` der , _9,,. � (signature) District Number J/6 a , Place / -n il Ly)104....e..eze . I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 8 l$f(' Place of Disposition r,,Oki,..i6;r0-4-1c.X.w..., (address) 111 CO ir (section) /11 (lot number) (grave number) ceName of Sexton or P n in Charge Premises r' t�'� Z. ( tom) Signature Title c- Ld'e_ (over) DOH-1555 (02/2004)