Steigerwald, Scott NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle - t Sex
SCa-tt' Mi _ ................. M
: .. . .. ..
Date of Death Age If Veteran of U.S. Armed Forces,
i 3 Z War or Dates
t99 _ .. . .............
Z Place of D th Hospital, Institution or
Uj City,Town or Village Street Address
wManner of Death Natural Cause Accident ❑Homicide ® Suicide Undetermined Ei Pending
. ...... ....:: .:
Circumstances Investigation
W Medical Certrfier Name T Title om. M � .
Address
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Death Certificate Filed Malta District Number 4560 Registe4Number
City,Town or Village r]
Dada-. Cemetery or Crematory
❑Burial
S ty i... .�Q 1.12i2.hS
9` . i . ..............rt
`). ... . ..
Address9CremaUon �-v r
Z Date Place Removed
O Removal and/or Held
F- and/or Hold .::::....
Address .............................................
Cn
0..... _::::.:
IL Date _................................:.::.: Point of:::.::....
an []Transportation by
0 Common Carrier ............................................. Shipment
..:
Destination ......:::.:
Disinterment Date Cemetery Address
......
Reinterment
Date Cemetery Address
Permit Issued to l�� 1 (� (� 1 r Registration Number
Name of Funeral Firm W IIQY�n �`Jl�ft g't�u1r1R r0.� Svn,�� 00 plc' 1
:..::: ..:.....
Address `
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.-< Name of Funeral Firm Making Disposition or to Whom
21 Remains are Shipped, If Other than Above
. ....... ......:.
W>.
Address
Permiss Rq is hereby granted to dispose of the human remains described above as indicated.
Date Issued Registrar of Vital Statistics `Go
(signature)
District Number 4560 PlaceMalta Town Hall, 2540 Rt. 9, Ballston Spa, N.Y. 12020
I certify that the remains
of the decedent identified above were disposed of in accordance with this permit on: p
Z; Date of Disposition Place of Disposition Al 116C zi
to
2 (address)
LUi"
Cl) (section) Ilot number) (grave number)
pName of Sexton r Person i Charge of Premis s �ir�/,'j ,D � ez�
Z (please print) ��
w' Signature Title / � �
DOH-1555 (10/89) p. 1 of 2 VS-61