Vanderwarker, Harold NEW YORK STATE DEPARTMENT OF HEALTH �' # 7(91
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Harold F.Vanderwarker Male
Date of Death Age If Veteran of U.S. Armed Forces,
9/19/2018 79 War or Dates 1958-1961
Place of Death r
Hospital, Institution
City, Town or Village Corinth Street Address 4ti64 Rte. 9N
Manner of DeathUndetermined
❑Natural Cause ❑Accident ❑Homicide ®Suicide El ❑Pending
rr Circumstances Investigation
Medical Certifier Name Title
Susan Hayes-Masa Coroner
,$,- Address
Ballston Spa, NY
Death Certificate Filed District Numb r Registey..N ber
City, Town or Village Corinth PLt.CS�
44 ❑Burial Date Cemetery or Crematory
9/20/2018 Pine View Crematory
'_❑Entombment Address
:"®Cremation Queensbury, NY
Date Place Removed
, El❑Removal and/or Held
. and/or Address
Hold
Date Point of
77L-+❑Transportation Shipment
by Common Destination
Carrier
i. ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
24 Church St.,Lake Luzerne, NY 12846
..; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
P ' Permission is hereby granted to dispose of the human remains ed abov as indicated.
0
Date Issued 9/20/2018 Registrar of Vital Statistics yak
(signature)
District Number Lk ss Place Town of Corinth
il
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 9Jtolit p LU� t,,,.Place of Disposition
(address)
air
{ (section) 4(lot number (grave number)
Name of Sexton or Person in Charge of Premises 4 r►ripk., e^�9'
- (pl ase print)
, Signature di -i- Title <r?fi ,
(over)
DOH-1555 (02/2004)