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Drouin, Guy R rife: if loss NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records II J Name First Middle / Last Sex Guy R.Drouin Male Date of Death Age If Veteran of U.S.Armed Forces, 12/07/2021 86 Years War or Dates H Place of Death Hospital,Institution or WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital 'p Manner of Death © Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined 0 Pending t) Circumstances Investigation W Medical Certifier Name Title CI Humaira Jami MD Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 717 ❑Burial Date Cemetery,Crematory or Facili Name 12/08/2021 Pine View Crematory ❑Entombment Address ICremation Queensbury Town,New York ❑Donation Z CI Removal Date Place Removed and/or and/or Held F- Hold Address N 0 a 1-1 Date Point of N ❑Transportation p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 5 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/08/2021 Registrar of Vital Statistics John Paul Franck(Electronically Signed) (signature) District Number 4501 Place Saratoga Springs, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ~Z Date of Disposition (7 I10N Place of Disposition Zli L t r r� � ll.1 (address) W CCCC (section) (lot number) (grave number) Sh 0 Name of Sexton or Person in Charge of Premise t" Mll Z (P! se print/ W iWt Signature Title i � ? G�=_..' DOH-1555(07/18)pi of 2 Public Health Law Sec. 4145(2b) Yi] Receipt Human remains of delivered on , 20 I Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#