Balfour, John NEW YORK STATE DEPARTMENT OF,iEALTH ,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
zit
k John Alfred Balfour Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/28/2017 77 Years • War or Dates
. Place of Death Hospital, Institution or
City, Town or Village Saratoga springs Street Address Saratoga Hospital
Manner of Death 0 Natural Cause E Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Stephen Offord MD
Ay, Address
4r 211 Church St,Saratoga Springs,New York 12866
k Death Certificate Filed District Number Register Number
" City, Town or Village Saratoga Springs 4501 534
❑Burial Date Cemetery or Crematory
11/01/2017 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
: ❑Removal and/or Held
and/or Address
,r`„r Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
El Disinterment
Date Cemetery Address
4❑Reinterment Date Cemetery Address
74 Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
VI
53 Quaker Rd,Queensbury,New York 12804
- Name of Funeral Firm Making Disposition or to Whom
ems_. Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/31/2017 Registrar of Vital Statistics yofnI'Tranck E(ectronicaaySigned-
(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:
tit Date of Disposition 03 3 I(] Place of Disposition ell,.U,: I Cn 1'011.—
(address)
(section) � (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises Ion ~ 5/mils`
Z �� (p ase print)
W Signature Z� ✓L•a� Title CWfm 1—
(over)
DOH-1555 (02/2004)