Teller, Walter NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit rermit
Name First Middle Last Sex
Walter J. Teller Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/16/2016 75 years . War or Dates
Place of Death Hospital, Institution or
City, T Street Address
Iliok C ei V X Saratoga: rings Wesle He Ith Care.Ce t®r
{ Manner of Death Natural Cause J Accident 0 Homicide Suicide i Undetermined Pending
IW Circumstances Investigation
W Medical Certifier Name Title
a Rink-.a Teetz M. D.
Address
131 Lawrence Street, Saratoga Springs N Y
Death Certificate Filed District Number Register Number
City, T )PJ Yi X Saratoga Springs _ 4501 16(O
❑Burial Date Cemetery or Crematory
❑Entombment 03/17/2016 Pineview Crematory
Address
[,Cremation Queensbury, N Y
Date Place Removed
Z❑Removal and/or Held
2and/or Address
f= Hold
0 Date Point of
t
Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
lui: Remains are Shipped, If Other than Above
Address
CC
ILI
C" Permission is hereby granted to dispose of the human remain 'be aboveps4 icated.
Date Issued 03/17/2016 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition .3JL(ri1. Place of Disposition -gt Uw frolis,, 130,),(aess)
ILI
(section) 4 (lot number (grave number)
Name of Sexton or Person in Charge of Premises ►ia 1. Stem/
iii
'/4
z
1 (plse print)
Signature Title rREA411614
(over)
DOH-1555 (02/2004)