Loading...
Hurlburt, John NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit n. Name First Middle Last Sex John Edward Hurlburt Male Date of Death Age If Veteran of U.S. Armed Forces, 03/15/2017 73 years War or Dates } Place of Death Hospital, Institution or City, TRIoutriokia Glens Falls Street Address Glens Falls Hospital 0 Manner of Death©Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending Ili Circumstances Investigation ta Medical Certifier Name Title Ct William Cleaver Attending Physician Address 100 Park St Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, TX900QrnqaX Glens Falls 5601 165 El Burial Date Cemetery or Crematory ❑Entombment 03/17/2017 Pine View Crematorium Address ail©Cremation Queensbury, NY 12804 Date Place Removed Removal and/or Held and/or Address w" Hold Ca 0 Date Point of to Li Transportation Shipment ct by Common Destination ej Carrier ❑Disinterment Date Cemetery Address El Reinterment Date Cemetery Address pilji Permit Issued to Registration Number iiill Name of Funeral Home Wilcox& Regan Funeral Home 01821 giiiii Address 11 Alqonkin Street Ticonderoga, N Y Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above • Address al tU 4` Permission is hereby granted to dispose of the human remains described above as indicated. wi Date Issued 03/17/2017 Registrar of Vital Statistics (A1 cA,4 p vv/..A.,,,eAllif (sitnature) District Number 5601 Place Glens Falls))4. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI Date of Disposition /Z07 Place of Disposition Pi7id t; C,ce.me,or (address Ul CC (section) (lot number) (grave number) 0 1 O Name of Sexto son in Charge of Premises �J tt. 1,Grpi c-e44 a _i f (please print) • Signature Title G/'e44-1u10'" (over) DOH-1555 (02/2004)