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Squires, Maurice K NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Maurice K.Squires Male Date of Death Age If Veteran of U.S.Armed Forces, 12/01/2021 78 Years War or Dates Place of Death Hospital,Institution or W• City,Town or Village Glens Falls Street Address 34 East State Street,Glens Falls, New York 12801 O Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending 2/1 Circumstances Investigation W Medical Certifier Name Title O Connie Goedert Coroner Address . 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 561 ©Burial Date Cemetery,Crematory or Facility Name 12/04/2021 Pine View Cemetery Entombment Address ❑Cremation Queensbury,New York ❑Donation Z Removal Date Place Removed and/or and/or Held H Hold Address N 0 Q. Date Point of (I) ❑Transportation a" by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment ;❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped,If Other than Above 2 Address Q W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/02/2021 Registrar of Vital Statistics `R96ertAndrew Curtis(E(ectronicafy Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ▪ Date of Disposition 12 .4 .21 Place of Disposition 21 Quaker Rd. Queensbury, NY 12804 2 (address) LU Hurpn 20E 1 tE tE (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises Connie Goedert (please print) W Signature Title Superintendent DOH-1555(07/18)p 1 of 2 Public Health Law Sec.4145(2b) 012884 Receipt , f Human remains of , .' k ' delivered on (- 4 ,' , 20 ..,„, ,./line View Cemetery Representing the funeral home named on burial permit ."- , ) 1 Official Funeral Directors Reg.or License# ' ' SQUIRES NAME Maurice K. _Squires Age: 78 Lot Owner: Joann Squires Lot# Huron 20E Grave# 1 Case: Concrete Died: 1 2. 1 .21 Interred: 1 2.4 .21 Funeral Home: Regan Denny Stafford Cemetery: Pine View