Tracey, Joseph NEW YORK STATE DEPARTMENT OF =iEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joseph P. Tracey Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 22, 2015 69 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause ❑ Accident I I Homicide ri Suicide ❑ Undetermined ri"—I Pending
CircumstancesInvestigation
Medical Certifier Name Title
Suzanne Bergin,
Address
3767 Main Street Warrensburg, NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 6 0 ( 3 ) 7
❑Burial Date Cemetery or Crematory
June 23, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
• ri Removal and/or Held
I I and/or Address
Hold
Date Point of
❑Transportation Shipment
{ by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
- s Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described abov6 as indicated.
Date Issued ! 2 2` 4.5 Registrar of Vital Statistics l.A' `A-
(signature)
vt District Number c6o / Place (r2_„„r k\ S 61...) (19
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
?(`4e
Date of Disposition 06/23/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) *� (lot number) (grave number)
Name of Sexton or Person in Charge of Premises f m 04 J.,/ r•vne
(please print)
Signature dti�w- Title Crew,4.4�lry A5�!
(over)
DOH-1555 (02/2004)