Ouderkirk, Eugen NEW YORK STATE DEPARTMENT OF HEALTH'-" IF 051
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eugene N. Ouderkirk Male
Date of Death Age If Veteran of U.S. Armed Forces,
Feb. 12-. 2 01 5 _ 80 yr s_ War or Dates no
Place of Death Hospital, Institution or
City, own •r Village Fort Ann Street Address 360 Clay Hill Rd.
Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined ❑Pending
Circumstances Investigation
tij
Medical Certifier Name Title
0 Goo egR T sQ2oA/z o n10
Address
3 A02 cPe?Ri< .Sr z 6/ S Pha-.L LS Aly/ado/
Death Certificate Filed District Number Register Number
fm
ffi City ow r Village Fort Ann 5754
Date Cemetery or Crematory
❑Burial r�6. /3, .0/- PineView Crematorium
L�-11 Address Town of Oueensbury, NY.
�x1 Cremation
Date Place Removed
❑RemovalEij _ _ ,r1or Held
and/or . Address
Eg Hold
Date Pent of
❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 0111 7
?.s Address
18 George St. ,• Fort Ann, NY. 12827
i. Name of Funeral Firm Making Disposition or to Whom
i"Remains are Shipped, If Other than Above
+ Address
Permission is hereby granted to dispose of the human r)17-
-,/ns described above,asii dicated
S s, �.
Date Issuedof J O�_egistrar of Vital Statistics ' ";` ���
,, (sig re
bli District Number 5 7 5 4 Place �I C r 'N � / / ", f c•2 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
WDate of Disposition Z/�i S Place of Disposition s c'-' Cr+�1br _...
(address)
LLI
CA
CC (section) (lot ) (grave number)
0 Name of Sexton or Pers in Charge of Premises �-,r number-JeAll-
z4- (please print)
W Signature Title C-041h'
(over)
DOH-1555 (9/98)