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Butler, Andy Ti.... ,,,),...----- %. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records •- ' '. Name First Middle Last Sex Andy Butler Male Date of Death Age If Veteran of U.S.Armed Forces, 06/01/2023 60 Years War or Dates ZPlace of Death Hospital,Institution or uJ City,Town or Village Plattsburgh Street Address Champlain Valley Physicians Hospital Medical Ctr p Manner of Death 0 Natural Cause Accident 0 Homicide 0Suicide Undetermined ri Pending W V Circumstances Investigation 0ILI Medical Certifier Name Title Althea Morrison MD Address 75 Beekman St,Plattsburgh,New York 12901 Death Certificate Filed City Of Plattsburgh District Number Register Number City,Town or Village 0901 253 Burial Date Cemetery,Crematory or Facility Name INE 06/06/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York ElDonation g❑Removal Date Place Removed H and/or and/or Held N Hold Address 0 a Date Point of Cl)❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number 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 — Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/05/2023 Registrar of Vital Statistics SyCvia Gad Parrotte(ECectronicalTy Signed) (signature) District Number 0901 Place City Of Plattsburgh I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— W Date of Disposition (4(,' /3 Place of Disposition ,�—,w 2 (address) Ili N Q (section) 7 (tot number (grave number) 0 Name of Sexton or Person in Charge of Premisestf Z ee //ease print/ IU Signature Title �iP.r'�»iN TV DOH-1555(07/18)p 1 of 2 U l 7016 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on . , 20 View Cemetery Representing the funeral home named on burial permit 1 Funeral Directors Reg.or License# -