Knickerbocker, David WO
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David Knickerbocker Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/11/2012 50 years War or Dates
1-- Place of Death Hospital, Institution or
ii City, Tow it Street Address
� C ARAAX Glens Falls Glens Falls Hospital
a Manner of Death p Nptural Cause ❑Accident ❑Homicide ❑Suicide pi❑Undetermined El Pending
LEI Circumstances Investigation
W Medical Certifier Name Title
Paul Bachman Coroner
Address
Warrensburg Health Center, Warensburg, NY
Death Certificate Filed District Number Register Number
City, TowsiglyilOgtxx Glens Falls 5601 113
❑Burial Date Cemetery or Crematory
['Entombment • Pine View Crematorium
Address
RiC,yemation Queensbury. NY 12804
Date Place Removed
t ❑Removal • and/or Held
and/or Address
i= Hold
I
0 Date Point of
N❑Transportation Shipment
a by Common Destination
Carrier •
❑Disinterment Date • Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton- Mc Dermott Funeral Home, Inc. 00134
Address
9 Pine Street Chestertown, N Y 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;' Address
c
Iu
Permission is hereby granted to dispose of the human remains described above as indicated.
MI Date Issued 03/12/2012 Registrar of Vital Statistics W CA}gp..ri i &)_'V
(sign ure)
District Number 5601 Place Glens Falls
1` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
lU Date of Disposition 3/13 f I Z Place of Disposition ii4Utca C14/1.40rI
(address)
I
til
CC (section) 1 - (lot number) c (grave number)
Ci Name of Sexton or Person in Charge Premises ^r.si J J l Awit
2 (please print)
iti
Signature Title C2Errttg1 f*
(over)
DOH-1555 (02/2004)