Cordes, John 07/25/2017 13:37 5183" 73446 t LIGHTS FUNERAL HOME PAGE 01/02
S2d
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section ... ....0......iim
Middle Last TSex
Male
Name First Cordes I
PA
John _
Date of Death Age If Veteran of U.S.Armed Forces,
tA July 20,2017 91 War or Dates WWII
Place of Death Hospital. Institution or
City,Town or Vill-! - Cohoes Street Address Villa:e Green Nursin: ionic
Manner of Death ►� Natural Cause Accident Homicide a Suicide El Undetermined Pending
Q QCircumstances Investigation
Medical Certifier Name II 1 Gha 6 1 grfral
i.A
1 'IAddrees, t4are LAM , I U I f ia 9 iN� I . 1 I
District Number Register Numbed�, ' City, erti r c- - Filed 1 off
r?, F•wn or Village 1 U
��.,
-�� =urial Date Cemetery or Crematory
- July 24,2017 Pine View Crematorium __
LI Entombment Address
(1 Cremation 51 Quaker Road,Queensburya NY 12804 ..- —
Date ' Place Removed
Z.❑Removal and/or Held
Cg and/or Address
ra Hold
' Date Point of
Q Transportation Shipment
by Common Destination
Carrier _
Date Cemetery Address
Q Disinterment
Renterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443 —
Address
53 quaker Ros,_Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
= Remains are Shipped, If Other than Above M _
0 Address
y4 tIi. Permission Is here y gr nted to dispose of the human rem ins d r ed above as indicated.
Date Issued Registrar of Vital Statistics
(- ture)
District Number /67 Place
:- 1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
us Date of Disposition 7/Z(/17 Place of Disposition mW (address)
VI
Kr
(section) (lot numb (!�
ve number)
O. Name of Sexton or P arge of Premises -. %a"/ �2ic-t
(per Print)
Signature Title G- /7
(over)
DOH-1555(02/2004)