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Shults, Donald NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit >: Name First Middle Lase Donald Ezra Sex Date of Death Male Age If Veteran of U.S. Armed Forces, Jul 3 1998 73 War or Dates of Death Hospital, Institution or Town Moreau Street Address 11 Cedar bane Manner of Death ©Natural Causes(]Accident ❑ Homicide Suicide Undetermined Pending ❑ ❑ Circumstances ❑ Investigation "��Medical Certifier Name Title David Foote Md Address Rt 4, Hudson Falls, N.Y. 12839 ?<' Death Certificate Filed District Number Register Number '` $ Town XMQQFe Moreau 4562 Date Cemetery or Crematory ❑ Burial July 6, 1998 Pine View Crematorium ® Cremation Address Tn Of Queensbury, NY 12804 Date Place Removed ❑ Removal and/or held and/or hold Address Date Point of ❑ Transportation by Shipment Common Carrier Destination Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit issued to Registration Number ..........Name of Funeral Firm Carleton Funexal Howie Inc. 00313 Address P.O. Box 67, 68 Main St., Hudson Falls, N.Y. 12839 ' >Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ?' Address Permission is hereby granted to dispose of the human remains desc ri ed bove as indicDateIssu � Registrar of Vital Statistics (Signar ) 4562 Moreau, NY District Number Place I certify that the re�mf ai�fs of the decedent identified above were disposed of in accordance with this permit on: Date of Dispositio Place of Disposition n �k! Q (address) (Section) (Lot Number) (Grave Number) Name of Sex nor Person in Charge of remises 4 v (Please Print) Signatur Title a j DOH-1555 (10/89) p. 1 of 2 VS-61