Dayton, John 4 gs1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John C Dayton Male
1 Date of Death Age If Veteran of U.S. Armed Forces,
z: 10/20/2018 63 Years War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
'e Manner of Death oT Natural Cause ❑Accident 111 Homicide n Suicide n Undetermined E Pending
Circumstances Investigation
Medical Certifier Name Title
Carlos Ares MD
eiti Address
ili 211 Church St,Saratoga Springs,New York 12866
l p Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 551
1 ❑Burial Date Cemetery or Crematory
10/23/2018 Pineview Crematory
❑EntombmentAA Address
vi®Cremation Queensbury Town, New York
Date Place Removed
n Removal and/or Held
and/or Address
Hold
Date Point of
tir
tn❑Transportation Shipment
" by Common Destination
TA Carrier
V: i—i Date Cemetery Address
4,A Li Disinterment
0
❑Reinterment
Date Cemetery Address
g
Permit Issued to Registration Number
^,,; Name of Funeral Home Densmore Funeral Home Inc 00448
'' Address
7 Sherman Ave,Corinth,New York 12822
i; Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
k.
Permission is hereby granted to dispose of the human remains described above as indicated.
3 Date Issued 10/22/2018 Registrar of Vital Statistics John PEranck(ECectronicalrySigned)
(signature)
District Number 4501 Place Saratoga Springs, New York
l I certify that the remains of the decedent identified above were disposed of in accordance/with this permit on:
ill Date of Disposition /b IZN Iig Place of Disposition p U�., IL,./rdr••,,,
ni (address)
(section) (lot number) c (grave number)
Name of Sexton or Person in Charge of Premises6 h �1w fD J 6.,+1�1
(pleafse print)
Signature Title �� P
(over)
DOH-1555 (02/2004)