VanBuskirk, Keith NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
• Keith L. VanBuskirk Male
Date of Death Age If Veteran of U.S. Armed Forces,
rf October 2, 2016 70 War or Dates Coast Guard
f ' Place of Death Hospital, Institution or
- City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ❑X Natural Cause Accident n Homicide n Suicide n Undetermined Pending
Circumstances Investigation
' Medical Certifier Name Title
J. Stratton Dr.
,r
Address
14 Manor Dr.,Queensbury,NY 12804
Death Certificate Filed District Number Register m uber
✓ City, Town or Village Glens Falls 5601 /�
❑Burial Date Cemetery or Crematory
October 4, 2016 Pine View Crematorium
❑Entombment Address
0 Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ElRemoval and/or Held
and/or Address
H Hold
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0 Date Point of
O.
n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 uaker Road, ueensbur ,NY 12804
„. Name of Funeral Firm Making Disposition or to Whom
1''` Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r mains d cribed above as i icat*d.
Y f+ /�
a Date Issued --� 65,Wg Registrar of Vital Statistics 2 /t -1 , �6
„:,:,,,,
(signature)
i ` 5601 Glens Falls
District Number Place
f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition / 7 /(D Place of Disposition Pi i9-U,"!) G/e.yrtarec%
W (address)
Cl)
O (section) ,,,(lot number) (grave number)
pName of Sexton or Person in Charge of Premises 3l._l'�Z t (��_rr-c26A I
W (please print)
Signature Title Gr-e.ko4 ai-10
(over)
DOH-1555(02/2004)