McPhee, John NEW YORK STATE DEPARTMENT OF HEALTH- -
Vital Records Section # Burial - Transit Permit
- - Name First �!� 4 G ��� �t,!
Sex
3oW 1M� s0
Date of Death A If Veteran of U.S.Armed Forces,
.;. 3131 / ,_ or Dates b. •/_0'
t - of Death .. , r�yInstitution
. C own or Villaget,k�`1nl S � -S S, -. Aidress (r �,�t., '.,3_"S Ft -j
E�'•� � - Undetermined 0 Pending
Suicide Manner of Death Natural Cause 0 Accident Q`i lomicide 'Q
r; Circumstances Investigation
°� Medical Certifier Name
Title
_-- Address /00 L nu)B-tio C� . Gidir -)s l c jU L / 2-
District Number ter r
::; Death Certificate Filed� I � �J
C• ) own or Village l -?➢Gtr hfl'i-(.c
U
:'El Burial Date Cemetery or rematori
Li il // P,,) U16-111-40
gif0 Address
1=DiXremation Q il 6vL__ (2-'D 00 t %AJ. g Oily Ay
>�<: Date
Place Removed /
`�'Q Removal ` and/or Held
and/or
Address
i Hold
Date f Point
nt of
M❑Transportation i Shipment
by Common Destination
- Carrier
__Q Disinterment
Date Cemetery Address
=- Date Cemetery Address
><< u Reinterment
n Permit Issued to Registration Number
;:; Name of Funeral Home a r • -1 .-. 1�er F_ I, a ' i.k t -- C 1 1 L4 Q --
iiiii v Address 11 Lai ye.iie- SA-. , aueensbury , N e v-,.\ y0.rk_ 12 Sl o L
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,-;. Address
;K�
i
.74
Permission is hereby rang to dispose of the human remains d dicated.
� Registrar of Vital Statistics ��jy
Date Issued Q�`1 ��
sn
District Number G 0/ Place
/. / /5 ,A/
._.„.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
71 Date of Disposition t-A-li Place of DispositionJR Utw Cev`•4 o ri.t -
-- (address)
rTA
(sedan) Anwnbe) (grave number)
r. Name of Sexton or P on in ChargePremises PIS il �' a w+nlCr"
&please print)
Signature
,,�`f k.- Title aMI41.0(
(over)
DOH-1555 (02/2004)