Stedman, Matthew f . _. 41- t( l 0
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Matthew J Stedman Male
' Date of Death Age If Veteran of U.S. Armed Forces,
August 3,2012 , 28 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Ui
Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
,�,, tu, Medical Certifier Name Title
Cir Richard F.Duff III,MD
Address
Saratoga Hospital, Saratoga,NY 12866
Death Certificate Filed Saratoga I Distri t Number Reger Number
City, Town or Village i t
• 5 Q I 3
❑Burial Date 8 Cemetery or Crematory
August 9;2012 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
N Hold
N
0 Date 1 Point of
5 Transportation 1 Shipment
p by Common Destination
Carrier
Disinterment Date ' Cemetery Address
Reinterment Date Cemetery Address
'a Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
.- Remains are Shipped, If Other than Above
" Address
t :
US
Permission is hereby granted to dispose of the human remains-desc 'b abo ' dicated
Date Issued $` `Q. I2017 Registrar of Vital Statistics
(signature)
„, District Number Lisp! Place Saratoga r;A%3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z � l.r/`
W Date of Disposition 4g-1- Q1 Place of Disposition .cUlcW storw`
2 (address)
W
CO
CL (section) /f� . (lot number) (grave number)
pName of Sexton or Person in Charge of Premises `' rr r' csAtli-
Z (please print)
W Title
Signature ((Le in A'roi'
(over)
DOH-1555(02/2004)