Kottman, Stephen Blaise LF 4
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Stephen Blaise Kottman Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/15/2022 74 Years War or Dates 1966-1972
H Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
WW Manner of Death
Natural Cause ❑Accident Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
G Medical Certifier Name Title
Karen Duane PA
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed City orAlly District Number Register Number
R,Town or
0101 0904
Burial Date Cemetery,Crematory or Facility Name
Address
ECremation Queensbury Town,New York
Donation
goRemoval Date Place Removed
F and/or and/or Held
CO Hold Address
0
CL Date Point of
Cl)❑Transportation
a by Common Shipment
Carrier Destination
ODisinterment 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
I.. Remains are Shipped,If Other than Above
2 Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/18/2022 Registrar of Vital Statistics u/kS spiegketmmcaIj'Sfmne$)
(signature)
District Number 0101 Place city ot Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition y11912t Place of Disposition .F. J..- j/^.1
2 (address)
W
CC CC (section) (lot numbe (grave number)
8 Name of Sexton or Person in Charge of emises _ �'t f •ft
z (please print)
Ill 7) ff'c,/n
Signature `�� Title
DOH 1555(07/18)p1of2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#