Wieneke Jr., Kuhrt NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kuhrt Wieneke JR Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/6/2017 80 War or Dates 1964- 1966
1.„, Place of Death Hospital, Institution or
Z City, Town or Village Town of Fort Ann,NY Street Address Lake Nebo Rd.Fort Ann,NY
0 Manner of Death I A'Natural Cause ❑Accident E Homicide [Suicide Undetermined Pending
1W Circumstances Investigation
tu Medical Certifier Name Title
C) Max Crossman MD
Address
65 Pouttney St.Whitehall,NY 12887
Death Certificate Filed District Number � Register Number
City, Town or Village Town of Fort Ann,NY ,5 l Jam- -% / 2--
El Burial Date Cemetery or Crematory
October 10, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
H Hold
V)
O Date Point of
O.
• ❑Transportation Shipment
Q by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
5 Address
IY.
W;
O. Permission is hereby granted to dispose of the human rema' s described above ndi ated.
Date Issued g —f o-0/7 Registrar of Vital Statistics / 1.e'�
(9' (signature)
District Number 4-26 Place �fi 2 / 2-1/ / 2 k 2-7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition /0 /It) fl Place of Disposition tint V•*w 4:•N•140 Co,
.2 (address)
W
CO
rL (section) // ,(lot number) r (grave number)
pName of Sexton or Person in Charge of Pr mises �y 1414 }'
Z 'please print)
Signature el Title
(over)
DOH-1555(02/2004)