Azer, William Seberheim 111 —N\........01-
NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
William Seberheim Azer III Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/31/2022 64 Years War or Dates 1976-1981
ZPlace of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death 71
. Natural Cause Ei Accident ❑Homicide Suicide Undetermined ❑Pending
W
V Circumstances Investigation
LLICI
Medical Certifier Name Title
Matthew Loftus PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 70
0 Burial Date Cemetery,Crematory or Facility Name
02/01/2022 Pine View Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
Z Removal Date Place Removed
H and/or and/or Held
N Hold Address
0
O. Date Point of
N L.I Transportation
p by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
CC
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/01/2022 Registrar of Vital Statistics Megan.Noln(Ekctronica8 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:
Il--
W Date of Disposition fi?.— Z._ Place of Disposition Pj y,.�, y;C,,., L,rtri ctk el
2 (address)
W
CD
(section) (lot number) (grave number)
GName of Sexton or Person' Charge of Premises J C t y S��:i,re.
Z (please print)
W Signature 4.�cy Title C/-t,tic�.�cr
DOH-1555(07/18)p 1 of 2
03.. ..) 00
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral honte named on burial permit
Official Funeral Directors Reg.or License# .