Heideman, Edwin 1 # --N i
NEW YORK STATE DEPARTMENT OF HEALTfri
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edwin P. Heideman Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 19,2017 85 War or Dates
8., Place of Death Hospital, Institution or
City, Town or Village Johnsburg Street Address 996 South Johnsburg Rd.
zn Manner of Death Undetermined Pending
X Natural Cause Accident Homicide Suicide a dmg
Circumstances Investigation
la Medical Certifier Name Title
0 Jennifer Donovan
Address
126 Ski Bowl Road,Johnsburg,NY 12843
Death Certificate Filed District Number J Register Number
6
City, Town or Village I
❑Burial Date Cemetery or Crematory
Entombment October 20,2017 Pine View Crematory
Address
l Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
! Hold
N
0 Date Point of
y 1 1 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
n° Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
1
tea Permission is hereby granted to dispose of the human remains described a ve as ind'c ed.
Date Issued /O.a 0• )"1 Registrar of Vital Statistics
signature)
District Number 5 4 ‹S LLI
c Place ` J
H
I certify that the remains of the decedent identified above were disposed of in accordanc ith this permit on:
W Date of Disposition /DiZnh Place of Disposition Kid—a lac j o ti,�
W (address)
N
0 (section) (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises t .,1 jt 4
Z (pi se print)
w Signature ��(/ ," Title fatE'1
(over)
DOH-1555 (02/2004)