Stokem, George NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George H. Stokem Male
li Date of Death Age If Veteran of U.S. Armed Forces,
April 14, 2017 90 yrs. War or Dates ' 44- ' 46
io Place of Death Hospital, Institution or
X City, Town or Village Hartford Street Address 60 Sky View Meadows Lane
Manner of Deathiiii Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
a. Medical Certifier Name Title
Thomas Coppens MD.
Address
3 Irongate Ctr. , Glens Falls, NY. 12801 •
Death Certificate Filed District Number Regist r Number
City, Town or Village Hartford 67-1-9
Date Cemetery or Crematory
Li Burial April 17, 2017 PineView Crematorium
m�� Address
Cremation Ouaker Rd. , Oueensbury, NY. 12804 _
Date Place Removed
0 Removal and/or Held
and/or Address
aHold
0 Date Point of
ilki❑Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
M. Permit Issued to Registration Number
Name of Funeral Hone Mason Funeral Home 01 1 1 7
i Address
18 George St. , P.O. Box 277, Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
21 Address
ID
Mi Permission is hereby granted to dispose of the human re ins dcescri a above as indicated.
RI
1 ►4/15/17 Registrar ql _ $ 'Us - `C.
gii
Date Issued e istrar of Vital Statistics
iiii
(si nature) ,
District Number 57 59 Place Town of Hartford, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition 41 /7 /7 Place of Disposition P, zeu,lL) Gf2,,Zz /
2 (address)
LL!
N
> (section) ` /, (lot number) - (grave number)
GName of Sexton or rson in Charge of Premises -J d ./,4.L c c zau..kL_
g (please print)
4..1 Signature `?Jr Title Lr32.n-uk-
/ (over)
DOH-1555 (9/98)