Barlow, Wayne NEW YORK STATE DEPAilTMEN1 OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Wayne Barlow Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 22, 2016 62 War or Dates
Place of Death Hospital, Institution or
Z' City, Town or Village Elizabethtown Street Address Essex Center
Manner of Death X Natural Cause I !Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
p Jeff Amidon MD
Address
81 Park Street,Elizabethtown,NY 12932
Death Certificate Filed District Number Register Number
City, Town or Village Town Of Elizabethtown 1552
❑Burial Date Cemetery or Crematory
December 28,2016 Pineview Cremtory
❑Entombment Address
❑X Cremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
and/or Address
Hold
N
0 Date Point of
fen" I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Heald Funeral Home 01766
Address
PO Box 282 7521 Court Street, Elizabethtown, NY 12932
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2' Address
CL
Permission is hereby granted to dispose of the human mains escribed above as ' dicated.
Date Issued /oZ—,29--/6 Registrar of Vital Statistics
signature)
District Number 1552 Place Town Of Elizabethtown
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition ill Jib Place of Disposition
(address)
N
(section) lot number (grave number)
pName of Sexton or Person in Charge of Premises �.y
Z (ple se print)
w Signature Title C t1Ib 11(
(over)
DOH-1555 (02/2004)