Vanderklish, Jack • A,
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
JACK DAVID VANDERKLISH MALE
Date of Death Age If Veteran of U.S.Armed Forces,
2/27/11 4HRS52MI War or Dates NO
Place of Death Hospital, Institution
City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
Manner of Death Natural AccidentUndetermined Pending
® Cause ❑ E Homicide ❑ Suicide ❑ Circumstances ❑ Investigation
Medical Certifier Name Title
MYLES BYRD MD
Address
43 NEW SCOTLAND AVENUE ALBANY, NY
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 391
Date I Cemetery or Crematory
❑ Burial 3/4/11 I PINE VIEW CREMATORY
❑ Entombment Address
�;` ® Cremation QUEENSBURY, NY
t Date Place Removed
Z Removal and/or Held
6 ❑ and/or
Address
1H' Hold
Q Date Point of
Transportation Shipment
❑ By Common Destination
0 Carrier
;;_ ❑ Disinterment Date Cemetery Address
_ ❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home SINGLETON-HEALY FUNERAL HOME 01522
Address
407 BAY ROAD QUEENSBURY, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indica e .
Date 3/2/11 i` rNQui� ,
Issued Registrar of Vital Statistics Ai.-
(signature)
, District Number 101 Place City of Albany, NY
4.
:' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition
(address)
ui
0 (section) (lot number) (grave number)
C
Name of Sexton or Person in Charge of Premises
(please print)
'` Signature Title
(over)
DOH-1555(02/2004)
4115
NEW YORK STATE DEPARTMENT OF HEALTH A - it Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
JACK DAVID VANDERKLISH MALE
Date of Death Age if Veteran of U.S.Armed Forces,
2/27/11 4HRS52MI War or Dates NO
Place of Death _ Hospital,Institution
City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
Manner of Death ® Natural ❑ Accident 0 Homicide (� Suicide ❑ Undetermined ❑ Pending
Cause Circumstances investigation
Medical Certifier Name Title -
MYLES BYRD MD
Address
43 NEW SCOTLAND AVENUE ALBANY, NY
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 391
Date Cemetery or Crematory
ff ❑Burial 3/4/11 PINE VIEW CREMATORY
is ElA
Entombment dd
fAddress
Cremation QUEENSBURY, NY
Date Place Removed
Removal and/or Held
❑ and/or Address —. _�.,
Hold
Date Point of
Transportation
' ' [ l By Common - Shipment -.
Carrier Destination
` ❑ Disinterment Rate Cemetery Address
ti"Ur' ,
: ;: Date Cemetery Address
� ,,• ❑ Reintern ent
,
Permit Issued To - _ .T W. Registration Number
Name of Funeral Home SINGLETON-HEALY FUNERAL HOME 01522
Address
407 BAY ROAD QUEENSBURY, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above _ —
Address
Permission Is hereby granted to dispose of the human remains described above as indica
Date 3/2/11 t
Registrarof Vital Statistics �
Issued `—
(signature)
District Number 101 Place City of Albany, NY
3w I certify that the remains of the decedent identified above were disposed of i ccordance with this permit on:
Date of Disposition,. 3"141A Place of Disposition "Vie, V il•"./ nJh�t a tt
i•.
a
(address)
i
(section) (et number (grave number)
Name of Sexton or Person in Charge of P lees C/r,Sim ry r
n,t
A�". . dtPhk-
- (p►ease print)
k Signature rTitle C(2 R Al t O L
(over)
DOH-1555(02/2004)