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Mayer, Jay G. /r Z Sr NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Jay G. MAYER Male Date of Death 1 Age4 If Veteran of U.S.Armed Forces, 3/3 pa 84 War or Dates 1961-1962 Place of Death Hospital, Institution or City, Town or Village Albany Street Address DVAMC 113 Holland Avenue Albany, NY 12208 Manner of Death©Natural Cause 0 Accident 0 Homicide 0 Suicide 0Undetermined ri Pending Circumstances Investigation Medical Certifier Name Title Richa Raushik MD. Address 113 Holland Avenue Albany, NY 12208 Death Certificate Filed Alban District Number Register Number City, Town or Village y 0198 01 5 ❑Burial Date Ve,i/�ea Cemetery or Crematory ❑Entombment Address CIA v'e i Cr frl ["Cremation ' 1 Q v.ed RC«..I QU ee/L4,7y, 0( 1a eazi- Date Place Removed IT Removal and/or Held and/or Address Hold Date Point of Transportation Shipment by Common Destination Carrier 0 Disinterment Date Cemetery Address Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home 6j4e At 140 Vlif IC-- Address ii Ill F lip1tG1" 5'r 4, f' GIA"0,5601 /Al Sot 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 huma e ins des ' ed a as indicated. Date Issued 0 3/0 3/2 0 21 Registrar of Vital Statisti j ame Ar ingt , Manager vs c (signature) District Number 0198 Place DVAMC, 113 Holland Avenue, Albany, New York 12208 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 3110 i zj Place of Disposition iL Ar,..- (address) (section) (lo umber) . (grave number) Name of Sexton or Person in Charge of Premises -. Ins L. '4'1'} (please pit) Signature -� Title ` (over) DOH-1555 (02/2004) Public Health Law Sec. 4145(2b) 14621 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#