Basque, Frank ti,
NEW YORK STATE DEPARTMENT OF HEALTH rR 23y
Vital Records Section Burial - Transit Permit
y• Name First Middle Last Sex
• �' Frank Basque i Male
;lir Date of Death 1 Age I If Veteran of U.S.Armed Forces,
04/02/2017 j 84 War or Dates
o
Place of Death Hospital, Institution oroa 73 RT
City,Town or Village ChesterisporR Street Address Deceased's Residence
Manner of Death Natural Cause 0 Accident ❑Homicide❑ Suicide jJ Undetermined ri Pending
Circumstances investigation
Medical Certifier Name Title
PAUL BACHMAN, /171 1
OR
34,4
Address
3767 Main ST. Warrensburg, NY 12885
Death -•ificate Filed District Numbr � Register umber
4441
City o •r Village �j ll
®Burial Date or Cremator i
11 04/03/2017 171/et/7e1 l%-e uJ ( /T 1 C /oci i/z�-r
, ,},❑Entombment
Address / / %
giCremation DeV--ee/Y/<�. If �/ 7 /�ij
Date Place Removed
Removal and/or Held
i' and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Oz' Disinterment Date Cemetery Address
tw� Date Cemetery Address
.o Reinterment
�� Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
-" 9 Pine St/P.O. Box 455 Chestertown NY 12817
OR OR
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
N
• Permission is hereby granted to dispose of the human remains decrib boy indicated.
Date Issued td 312.o 17 Registrar of Vital Statistics
(signature)
VA District Number 5 j_ Place 1 O`1 ei \ C X
OA
i" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
{ Date of Disposition t1/1 in Place of Disposition at Viw i ctdni
(address)
(section) iii (lot number) (grave number)
Name of Sexton or Person in Charge of Premises /Iris kit- `5-t�ni(4
lease print)
Signature 47' Title (K4Ea �.2
(over)
DOH-1555(02/2004)