Martin Jr, Alva NEW YORK STATE DEPARTMENT OF HEALTH ' • - &qC.
Vital Records Section Burial - Transit Permit
1,0 Name First Middle Last Sex
Alva R. Martin -..- Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/21/2015 87 War or Dates World War II
PlaceestReath Hospital, Institution or
City, ow or Village No d °SPX' , Street Address Adirondack Tri County Health Care Center
Manner of Death Q Natural Cause 0 A • ent ❑Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
tie
James F. Hindson, 40
Address
112 Ski Bowl Rd North Creek, NY 12853
,, Deat rtificate Filed \ \ C ` District Number �� 5 Register Number �?J1
City ow or Village ��pC18
Date Cerra--dry or Crematory
'`�� ❑Burial '_
L� ; 09/23/2015 P R/ /A-C er-e l9/1 Gt j 0 l t i/kvi
❑Entombment Address
®Cremation (9tw, c 1::,LfY
, ,
. Date Place Removed
S ❑ Removal
and/or Held
and/or Address
Hold
k Date Point of
} ❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reintermentz, Li —
Date Cemetery Address
kPermit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
N
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
.£ 1 Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem de, 4scribed ab ye as in is ted.
4, Date Issued 9-a)-15- Registrar of Vital Statistics 1') l '
(signature)
District Number 5t) Place r] \/IN nab t 4.
I certify that the remains of the decedent identified above were disposed of in accordance with t ermit on:
a )
Date of Disposition q/13I tc Place of Disposition 4?.I) Cw a:0,-
(address)
I
(section) ni (lot number) (grave number)
;ems
z Name of Sexton or Person in Ch rge of Premises e,S�— 5:�..
( lease print)
aSignature Title l "
cY
(over)
DOH-1555 (02/2004)