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VanDerwarker, John 13� NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex (; John David VanDerwarker Male �Hy Date of Death Age If Veteran of U.S. Armed Forces, 02/10/2018 75 Years War or Dates 1959-1966 Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital f. Manner of Death Undetermined Pending ,tta ©Natural Cause �Accident �Homicide �Suicide � � Circumstances Investigation Medical Certifier Name Title William Cleaver MD Address 100 Park St,Glens Falls,New York 12801 • Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 74 ['Burial Date Cemetery or Crematory 02/12/2018 Pine View Crematorium ❑Entombment Address ®Cremation Queensbury, New York Date Place Removed ❑• Removal and/or Held and/or Address Hold • Date Point of Q Transportation Shipment by Common Destination Carrier Q Disinterment Date Cemetery Address vcgi Reinterment Date Cemetery Address Yap== Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above Address A 3: Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/12/2018 Registrar of Vital Statistics Wp6ertA Curtis(ECecrronicallySigned) (signature) r. District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 1ll3Ilg Place of Disposition (address) (section) /(lot number) (grave number) • Name of Sexton or Person in Charge of Pr mises �4,1 (Ise print) Signature Title /1217milliVL (over) DOH-1555 (02/2004)