Persons, Wallace I # 9
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Per it
a Name First Middle Last Sex
g_x Wallace O. Persons Male
_° Date of Death Age If Veteran of U.S. Armed Forces,
December 11, 2017 70 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Warrensburg Street Address 237 Schroon River Road
Manner of Death X Natural Cause I I Accident I I Homicide [ Suicide Undetermined Pending
U: Circumstances Investigation
0.
la Medical Certifier Name Title
?° Paul Bachman MD
$_ Address
3767 Main Street,HHHN,Warrensburg,NY 12885
ft Death Certificate Filed District Number Register Number
City, Town or Village Warrensburg 5660
❑Burial Date Cemetery or Crematory
December 12,2017 Pine View Crematory
❑Entombment Address
1I Cremation _ 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z —Removal and/or Held
Q and/or Address
1,--: Hold
N
0 Date Point of
135 I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
i: Permit Issued to Registration Number
z„ Name of Funeral Home Alexander-Baker Funeral Home 00037
° = Address
}
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
_ Remains are Shipped, If Other than Above
Address
Le
W.
$$ Permission is hereby granted to dispose of the human i escribe above as indicated.
Date Issued 12/12/17 Registrar of Vital Stat tics /h' e (e
/ ' (signature)
;if District Number 5660 Place Warrensburg,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition !Zirtin Place of Disposition ps.a.,, 1+*.4tcit'+
2 (address)
W
O (section) (lot number) (grave number)
0Name of Sexton or Person in Charge of Pre ises 4 ,.. 5e '0
Z (pi se print)
W atmot it
Signature �- Title
(over)
DOH-1555 (02/2004)