Butler, Jameswi
NEW YORK STATE DEPARTMENT OF HEALTH s Burial - Transit Permit
Vital Records Section
Last Sex
Name First Middle Male
Harold Butler
James If Veteran of U.S. Armed Forces,
Date of Death Age 1960 - 1962
10/15/2019 80 War or Dates
Place of Death Hospital, Institution or
'Z City, Town or Village Town of ueensbu NY Street Address 52 Waver/ Place, Queen , NY
Undetermined Pending
GManner of Death a Natural Cause Accident [� Homicide Suicide Circumstances Investigation
W Medical Certifier Name
C
Address
Death Certificate Filed
City, Town or Village Town of Queensb
❑ Burial Date
October 18, 2019
El Entombment Address
® Cremation
Date
Removal
and/or Address
Hold
Transportation
by Common
Carrier
Disinterment
Reinterment
Date
Destination
Date
Date
Title
District Number Register Number
NY 5 usli 1 152,
Cemetery or Crematory
Pine View Crematorium
51 Quaker Road, Queensbury, NY 12804
and/or Held
Point of
Shipment
Cemetery Address
Cemetery Address
Permit Issued to
Name of Funeral Home Regan Denny Stafford Funeral Home
Address
53 Quaker Road, Queensbury, NI' 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Registration Number
01443
Permission is hereby granted to dispose of the human remains described above as indicated.
Registrar of Vital Statistics
Date Issued t I �C - a D I9 (signature)
District Number 5 t, 5 1 Place �k)y e C. ns
I certify that the remains of the decedent identified above were �sposed of in accordance with this permit on:
Date of Disposition 10111111 Place of Disposition . I �� f'1
(address)
(section)
Name of Sexton or Person in Charge of
Premises
Signature G-'
DOH-1555 (02/2004)
(Jot number)
r 1 WLI
(pleAse print)
Title 4f -&/
(grave number)
(over)
PUBLIC HEALTH fAW
§ 4145. Deaths; burial and removal permits; disposition of remains.
1. No person in charge of any premises on which interments, cremations and other disposition of the body of a deceased person are made
shall inter or permit the interment or other disposition of any body unless it is accompanied in this article. by a burial, cremation or transit permit, as provided
2. The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition, before
interring or otherwise disposing of the body; or shall attach the removal or transit permit to the box containing the body, when shipped
transportation company, which pped by any
permit shall accompany the remains to its destination, where if within this state, it shall be delivered to the
Person in charge of the place of burial or other disposition.
3. The person in charge of the place of burial or other disposition shall endorse upon the permit, the date of interment, or cremation or other
disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of
interment, cremation or other disposition.
4. When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge, the
funeral director or undertaker shall (a) sign the burial or removal permit, giving the date of the burial; (b) write across the face of the
words "No person in charge;' and (c) file the burial or removal cemetery
the
is located. permit within three days with the registrar of the district in which the cemetery
5. The person in charge of the place of burial, cremation, or other disposition shall keep a record of all bodies interred or otherwise disposed
of on the premises under his charge, in each case stating the name of each deceased person, place of death, date of burial or disposal, and
name and address of the funeral director or undertaker, which record shall at all times be open to official inspection.
at Mori T,
Public Health Law Sec. 4145(2b) 0 1-3 0 1 a
Receipt
Human remains of
Pine View Cemetery
Official
delivered on
, 20
Representing the funeral home named on burial permit
Funeral Directors Reg. or License #