Burkhart, Vernon J cJNEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Vernon C. Burkhart Male
Date of Death Age • If Veteran of U.S. Armed Forces,
>%r August 15, 2016 88 War or Dates Korean
`� % Place of Death Hospital, Institution or
1
City, Town or Village Queensbury Street Address 132 Seelye Road
Manner of Death I X'Natural Cause ❑Accident n Homicide ❑Suicide ❑Circumstances Undetermined n Investigation Pending
Medical Certifier Name Title
Dr.Robert Evans MD
Address
1 Irongate Center,Glens Falls,New York 12801
Deat -,' ate File , , �,Q } DistrictNumber glter Number
Cit , Town .r illage b (�
El Bu . Date Cemetery or Crematory
❑Entombment August 17,2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
y ['Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
<:> 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
y�,� Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remins described move as indicated.
Date Issued 2) l ul I ‘ Cp Registrar of Vital Statistics
(signature)
District Numbeic 'Th Place �jl(___,-„,, c 5 Q -{\N4:3
I certify that the remains of the decedent identified above were disposed of in acc dance th this permit on:
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'- "f Disposition S/(Z Jjb Place of Disposition eK(L-• r_-
(address)
(section) (lot number) (grave number)
narge of Premises _1
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( lease print)
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(over)