O'Rourke, Stephen E. (2) NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last 7Ma
Stephen E.O'Rourke
Date of Death Age If Veteran of U.S.Armed Forces,
03/17/2020 58 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 9 Queensbury Place,Queensbury Town,New York 12804
p Manner of Death Natural Cause Accident El Homicide ❑Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
Christopher Mason DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 45
Burial Date Cemetery,Crematory or Facility Name
03/18/2020 Pine View Crematory
Entombment Address
iCremation Queensbury,New York
❑Donation
Z Removal Date Place Removed
and/or and/or Held
H asHold Address
O
a. Date Point of
N ❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
p- Remains are Shipped,If Otherthan Above
R Address
n' Permission is hereby granted to dispose of the human remains described above as indicated.
03/18/2020 aroCrne�lde and Barber Ekctronicall S o ne
Date Issued Registrar of Vital Statistics �' A � .Y to d)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I
Z
W Date of Disposition 3_/(�_2�1 Place of Disposition ,` /
2 (address)
W
U) (sedion) (lot number) (grave number)
8 Name of Sexton or Person in rge of Premi 15'
(please print/
W
Signature �• Title
I
DOH-1555(o7/18)p 1 of z
I
Public Health Law Sec. 4145(2b) 01-3 4 3 8
Receipt
Human remains of delivered on , 20
Pin6 View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#