Koke, John te
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
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Name First Middle Last Sex
''f John Koke Male
,� Date of Death Age If Veteran of U.S. Armed Forces,
August 2016 81 War or Dates n/a
��f g 3,
'`{ Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 53 Cascade Court
Manner of Death a Natural Cause El Accident ['Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
• �y Christopher Hoy,MD
`a,r .r
Address
itg Queensbury,NY
:, Death Certificate Filed District Number Reg ter umber •
F�_•FCity,Town or Village Queensbury, NY 5657❑x Burial Date Cemetery or Crematory
August 8,2016 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road Queensbury, Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
CO
Q Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
-,, Permit Issued to Registration Number
%% Name of Funeral Home Regan Denny Stafford Funeral Home 01443
rr
'' Address
%' 53 Quaker Road,Queensbury,NY 12804
` F Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
.g.0 Permission is hereby granted to dispose of the human re ains described above as indicated.
} ,% Date Issue's ��--1U/ /l Re 'istrar of Vital Statistics >�_q
, 0...s,,
f f (signature)
*A,:z,,'S District Number Place t o (:'
I certify that the remains of the decedent identified above were disposed of in a corda ce with this permit on:
Z NY
W Date of Disposition 8/8/2 01 6 Place of Disposition Pine View Cemeter , Queensbury,
g (address)
W Seneca 1C 1
ONC
(section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premise Connie L. Goedert
W
C-�1 (please print)
Signature i _t . A 4 Title Cemetery Superintendent
(over)
DOH-1555(02/2004)