Durkin, John # IV)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John E. Durkin Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 16,2011 69 War or Dates
I.., Place of Death Hospital, Institution or
Z City, Town or Village Warrensburg Street Address 14 Newton Street
pManner of Death X Natural Cause Accident Homicide Suicide Undetermined 'Pending
W Circumstances Investigation
uui Medical Certifier Name Title
0 Nancy Carney MD
Address
HHHN,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Warrensburg,NY 5660 l 2-
❑Burial Date Cemetery or Crematory
ri
Entombment August 16,2011 Pine View Crematory
Address
ID Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
t' Hold
fn
a Date Point of
N 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 00035
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
g Address
n.
Permission is hereby granted to dispose of the human r, s 'escribed •bove as indicated.
Date Issued 08-16-11 Registrar of Vital Statisti
(signature)
District Number 5660 Place Warrensburg,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Ie
cu Date of Disposition %vat( Place of Disposition �� 1 t1pr,�,+ Crvwc f orm..._
Lu (address)
U,
0 (section) i7 - (lot ry►ber) (grave number)
ZName of Sexton or Person in Charge of remises C �c,. - t-iKC--
AIL
(please print)
Signature LI Title Crl�p�
(over)
DOH-1555(02/2004)