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Burnham, Wayne N Sr. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Wayne N.Burnham Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 09/04/2023 90 Years War or Dates 1- Place of Death Hospital,Institution or City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc © Manner of Death ri Natural Cause Accident n Homicide Suicide Undetermined 1-1 Pending V Circumstances Investigation W Medical Certifier Name Title CI Nicole Humiston NP Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 76 RBurial Date Cemetery,Crematory or Facility Name 09/06/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation O Removal Date Place Removed and/or and/or Held t- Hold Address N 0 O. Date Point of 0Transportation Q by Common Shipment Carrier Destination Date Cemetery Address Disinterment Date Cemetery Address C Reinterment Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above a Address tle O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/05/2023 Registrar of Vital Statistics f?imeeL Maloney(EkctronicaQSgner) (signature) District Number 5755 Place Town Of Fort Edward I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition q`i i�3 Place of Disposition riz_____ 2 (address) W rc (section) /j (lot number) (grave number) 8 Name of Sexton or Person in Charge of Pre ises Pr' (pse print) W Signature Title � ���� DOH-15551o7/t8)p 1 of 2 i f 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#