Sommer, Sr. Herbert NEW YORK STATE DEPARTMENT OF HEALTH _ r I 00
Vital Records Section - Burial - Transit Permit
;n„ Name First Middle Last Sex
Herbert R Sommer, Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 15, 2012 83 , War or Dates
Fes Place of Death Hospital, Institution or
:Z City, Town or Village Saratoga Springs Street Address 83 King Rd.
ri; Manner of Death n Natural Cause Accident Homicide Suicide Undetermined Pending
US Circumstances Investigation
tis: Medical Certifier Name Title
p John Koella,MD
Address
3049 Rt 50 N Saratoga,NY 12866
>i. Death Certificate Filed District Number � Register Number
City, Town or Village Wilton '�
❑Burial Date Cemetery or Crematory
February 16, 2012 j Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
9 and/or Address
,l— Hold
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O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
1-1 Reinterment Date Cemetery Address
:_: Permit Issued to i Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
k*.: Remains are Shipped, If Other than Above
E Address
10
F,t' Permission is hereby granted to dispose of the human remains described above�as indicated.
Date Issued ci4�, Registrar of Vital Statistics l � IS7/. �
(si ature)
, District Number % Place Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /�
W Date of Disposition ce ,,
fl t tout Place of Disposition ,�UtG,y Cre�,.�`f er,,..�.
W (address)
co
rG (section) , (lot numb (grave number)
pName of Sexton or Person in Ch rge of Premises 71tr .)L- e{ -
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Signature Title (e r A-!Oi
(over)
DOH-1555(02/2004)