Veldmeyer Jr, John ✓'‘
NEW YORK STATE DEPARTMENT OF HEALTH �10
/
Vital Records Section Burial - Transit Permit
4:0.::: Name First Middle Last Sex
John Veldmeyer,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
r:.. September 1, 2015 85 War or.Dates -
., Place of Death Hospital, Institution or
City, Town or Village Chester Street Address 60 Rock Ave
, Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Paul Bachman
; ii' Address
V3767 Main Street,Warrensburg,NY 12885
;..; Death Certificate Filed District Number Register Number
;l_: City, Town or Village Chester 6(0.6- 7
❑Burial Date Cemetery or Crematory
❑Entombment September 3, 2015 Pine View Crematory
Address
❑x Cremation Quaker Road, Glens Falls,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
#_- Hold
Cl)
0 Date Point of
g Transportation Shipment
`a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
; .. Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
4{' Address
. 53 Quaker Road, Queensbury,NY 12804
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 r-m.'ns d-s r'• -d abo"e as indicated.
.:1 Date Issued 9-3 'SE. Registrar of Vital Statistics / / / ., aLlp ir
.,, (signature)
1';;: District Number�'62. ' Place Chester,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 4 bil/C Place of Disposition
W (address)
co
Z0 (section) 7.(lot number)( (grave number)
Name of Sexton or Person in Charge of Premises t1 en.
W g S release print)
Signature Title ft�6�h i
(over)
DOH-1555(02/2004)