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Staats, Jr. Walter NEW YORK STATE DEPARTMENT OF HEALTH'' Vital Records Section Burial - Trans-it Permit Name First Middle Last Sex Walter F. Staats,Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, August 20,2012 59 War or Dates i. Place of Death Hospital, Institution or Z: City, Town or Village Horicon Street Address 96 Grassville Rd. p Manner of Death I l i I I Undetermined Pending X Natural Cause Accident Homicide Suicide W Circumstances Investigation tu Medical Certifier Name Title , William Orluk L Address Chester Health Center,Chestertown,NY 12817 Death Certificate Filed District Number Register Number City, Town or Village Horicon 5654 v2 ❑Burial Date Cemetery or Crematory August 21,2012 Pine View Crematory bomb Address LI Cremation 21 Quaker Rd., Queensbury,NY 12804 Date Place Removed Z Removal and/or Held O and/or Address �' Hold u) 0 Date Point of N Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00035 Address • 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom ,i- Remains are Shipped, If Other than Above -2 Address _L Permission is hereby granted to dispose of the human remains described above asf indi eted. Date Issued aO 5?©/ Registrar of Vital Statistics 2� t-iSz " (signature) District Number 5654 Place Horicon I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z �7 /� w Date of Disposition q-Z(-tt. Place of Disposition 1►.4�(v C.h,,..j dress... LU (address) f/) Ce (section) (lot numb r) (grave number) Z Name of Sexton or Person in Charge f Premises jhus'f r lti..i`} 1 (please print) W Signature AL, Title atm per-A, (over) DOH-1 555 (02/2004)