Supry Jr, Fred NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Fred L. Surry, Jr. *dale
Date of Death Age If Veteran of U.S. Armed Forces,
Aug. 22, 1997 31. War or Dates No
Place of Death Hospital, Institution or on Hidden Valley Rd. (across From
City, Town or Village Lake L uzerne Street Address entrance to P!AcGewood Dr. )
Manner of Death E]Natural Cause ❑Accident Homicide ®Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Dr. Haul Bachman MD
Address
warnansburg mpw Yor',
Death Certificate Filed District Number Register Number
City, Town or Village Lake Luzerne 5676
Date Cemetery or Crematory
El Burial 8/26/97 Qinevi.ew Crematory
IgJCremation AddressOueenshury, New Yor'c 12804
Date Place Removed
8❑Removal and/or Held
-- and/or Address
Hold
Q Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer. Funeral dome, Inc. 0022A
Address
24 Church Street, Lake Luzerne, NY 12846
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 mains described above as indicated.
Date Issued 8/2=/`''7 Registrar of Vital Statistics
gnature)
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Place Lake Luzerne, New York
District Number,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition Place of Disposition / l,E!,�
a (address)
W
VJ
> (section) (lot number (grave number)
Name of Sexto or Person n Charge of Pr ises '��/� J `�
(please print) !*--�
W Signature Title G ! 1
DOH-1555 (10/89) p. 1 of 2 VS-61