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Stephenson, Paul F . . tt k 1 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Paul F.Stephenson Male , Date of Death Age If Veteran of U.S.Armed Forces, 08/02/2021 68 Years War or Dates }. Place of Death Hospital,Institution or IliCity,Town or Village Johnsburg Town Street Address Elderwood at North Creek p Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending 8 W Circumstances Investigation Medical Certifier Name Title CI Suzanne Barth PA Address 112 Ski Bowl Rd,Johnsburg Town,New York 12853 Death CertificafFiledi" District Number Register Number City, brVillage North Creek 5655 P7 ❑burial Date Cemetery,Crematory or Facility Name 08/06/2021 Pine View Crematory ❑Entombment Address 0 Cremation Queensbury Town,New York ❑Donation OZ Date Place Removed ❑Removal F-- and/or and/or Held N Hold Address 0 N ❑Transportation Date Point of p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment ❑Reinterment Date Cemetery Address Permit Issued to Registration Number 4. Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom l Remains are Shipped,If Other than Above t- Address CC IL' a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/05/2021 Registrar of Vital Statistics 7(Atfileen C.Gorah(ECectronicaCCy Signed) (signature) District Number 5655 Place North Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1 W Date of Disposition diI q It Place of Disposition �'a��� ��0r�` W (address) CO X' (section) ( t number) (grave number) $` Name of Sexton or Person in Charg f Premises A 4 L S.....ht W (pleasent) ` Signature �/' Title ° t<,K,�r DOH-1555(07/t8)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on ' , 20 F � f . Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#