Burger, Timothy NEW YORK STATE DEPARTMENT OF HEALTH 4
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Timothy O. Burger Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 16,2016 52 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Thurman Street Address 34 Athol Rd.
Manner of Death *Natural Cause Accident Homicide X Suicide Undetermined Pending
* Circumstances Investigation
7 Medical Certifier Name Title
Timothy E.Murphy Mr
Address
52 Haveland Ave.,Glens Falls,NY 12801
Death Certificate Filed District Number Register N ber
_.E City, Town or Village Thurman 5659 d
❑Burial Date Cemetery or Crematory
December 19,2016 Pine View Crematory
II Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
u) Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
I1 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
;< n Name of Funeral Home Alexander-Baker Funeral Home 00037
G Address
3809 Main Street,Warrensburg,NY 12885
: ', Name of Funeral Firm Making Disposition or to Whom
eA Remains are Shipped, If Other than Above
Address
Ait
�" Permission is hereby granted to dispose of the human ains described above as ndicated.
Date Issued X02/I 16 g Registrar of Vital Statistics 4ZL.P � „---/
signat e)
District Number 5659 Place T/O Thurman
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition I t Ito I)b Place of Disposition llncld-N, /r v r;_._
(address)
W
CO
CL (section) `i(lot numb*. (grave number)
pName of Sexton or Person in Charge of Premises / r,rfpi-.. �t-+ I'
W (please print)
Signature G.-C Title Ck
(over)
DOH-1555 (02/2004)