Butler, Joseph If 1
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NEW YORK STATE DEPARTMENT OF HEALTH „ ___.
Vital Records Section Burial - Transit Permit
4 Name First Middle Last Sex
Joseph A.Butler Male
rif Date of Death Age If Veteran of U.S. Armed Forces,
11/01/2017 80 Years War or Dates
-. Place of Death Hospital, Institution or
7 City, Town or Village Johnsburg Town Street Address Adirondack Tri-County Nursing And Rehabilitation Center,
Manner of Death Ed Natural Cause 0 Accident 0 Homicide 0 Suicide ElUndetermined El Pending
Circumstances Investigation
T. Medical Certifier Name Title
James Hindson MD
OM
Address
m 112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
;- City, Town or Village North Creek 5655 29
.14❑Burial Date Cemetery or Crematory
61 11/03/2017 Pine View Crematory
❑EntombmenttAz Address
®Cremation Queensbury Town, New York
Date Place Removed
Removal
and/or and/or Held
Address
Hold
Date Point of
5 0 Transportation Shipment
- by Common Destination
tt-
A. Carrier
Disinterment Date Cemetery Address
Reinterment0
Date Cemetery Address Lir-I
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
112 3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
it Date Issued 11/02/2017 Registrar of Vital Statistics Jo Smith fECectronicadySigned
R.
(signature)
District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ii/6(n Place of Disposition f?,4,,/ Iti„,,10,,...,
(address)
rir
(section) /lot number) (grave number)
Name of Sexton or Person in Charge of Premises ALA NPA4#
Go
(p/eae print)
Signature Title I'Ir++t5�,,
v (over)
DOH-1555 (02/2004)