Winch, Jr. Vernon NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Vernon O. Winch,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 4,2012 73 War or Dates
i-. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
wW Manner of Death
X Natural Cause ( (Accident ( �Homicide Suicide ( (Undetermined Pending
0Circumstances Investigation
C Medical Certifier Name Title
Noelle M.Stevens
Address
100 Broad St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 3 i 7
El Burial i Date Cemetery or Crematory
D Entombment July 6,2012 Pine View Crematory
Address
Jx Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z I- (Removal and/or Held
and/or Address
F" Hold
rn
0 Date ' Point of
N I (Transportation _ Shipment
p by Common Destination
Carrier
( I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2 Address
Cd
a
Permission is hereby granted to dispose of the human remains described above aspindicated.
Date Issued Z /5// Z Registrar of Vital Statistics
Gam_w'gnature
District Number 5601 Place Glens Falls it‘/ y i %V 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�Z �"t .,'tort._
Date of Disposition 7 1(,1 11 Place of Disposition iw Loy
!J 1 (address)
cn
it
p (section) jlot number) (grave number)
ZName of Sexton or P rson in Cha ge of Premises Aiiirift. eii,,4�'�'
Signature (please
g ature L 4- Title C 'o
(over)
DOH-1555 (02/2004)