West, Travis r r # �L1 NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Travis M. West Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/01/2018 25 years War or Dates
1 Place of Death Hospital, Institution or
W City, ToNX;QX\XXX Saratoga Springs Street Address 4 Clubhouse Drive
W Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined Ej Pending
Circumstances Investigation
W Medical Certifier Name Title
Q Daniel J. Kuhn Coroner
Address
40 McMaster Street, Ballston Spa, N Y 12020
Death Certificate Filed District Number Register Number
ft City, To)XXMAXi XX Saratoga Springs 4501 84
❑Burial Date Cemetery or Crematory
['Entombment Pineview Crematory
Address
[Jremation Queensbury, N Y
Date Place Removed
9.❑Removal and/or Held
and/or Address 1
in
Hold
0 Date Point of
❑Transportation Shipment
0 by Common Destination
iig Carrier
❑Disinterment Date Cemetery Address
>> ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
I
U1
17 Permission is hereby granted to dispose of the human remai ri abowr4 ' dicate
iiii Date Issued 02/05/2018 Registrar of Vital Statistics i •
(signature)
IR District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ul Date of Disposition Z/g jig Place of Disposition :fLti,,.. ! -(0--
2 (address)
UI
CC (section) (lotr mber) (grave number)
0Ct Name of Sexton or Person in Charge of Pr mises /Ar.ITL. j'^"i'
(please rint)
ta
Signature Title (R(M1121!
(over)
DOH-1555 (02/2004)