Fisk Sr., Terrence 4 r
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Pe mit
" Name First Middle Last Sex
Terrence W. Fisk,Sr. Male
_. Date of Death Age If Veteran of U.S. Armed Forces,
`, 6/10/18 68 Vietnam
_414
War or Dates
• Place of Death Hospital, InstitutiRn
City, Town or Village Corinth Street Address yak St., Apt. 1
Manner of Death® Natural Cause ❑accident Homicide Suicide ❑ Undetermined El❑Pending
IT
Circumstances Investigation
• Medical Certifier Name Title
Amy Johnson, MD
Address
ii-8 Palmer Ave.,Corinth, NY
Death Certificate Filed District RegistE:rumber
City, Town or Village //�N
❑BAi urial Date Cemetery or Crematory
6/14/18 Pine View Crematory
❑Entombment Address
• BCremation Queensbury, NY
Date Place Removed
1_,
Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
• Reinterment Date Cemetery Address
i_
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
+FAddress
1 24 Church St., Lake Luzerne,NY 12846
-
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
Address
• Permission is here y granted to dispose of the humane escribgd abo a as indicated.
A
cori,,,,..
Date Issued (�,/�,� �g Registrar of Vital Statistics ��
(signature)
l District Number Place
ig
}'x I certify that the remains of the decedent identified above wer Isposed of in accordance with this permit on:
• Date of Disposition IP119lig Place of Disposition P�U,� 4„40_
(address)
(section) (lot number) (grave number)
ses
Name of Sexton or Person in Charge of,Premi
/4,1 S �
Signature lease print)
Title rfr "' h4
t
(over)
DOH-1555 (02/2004)