Jurgens, Fred # 1.,
NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
<: Name First Middle Last Sex
Fred H. Jurgens Male
Date of Death Age If Veteran of U.S. Armed Forces,
11 / 25 / 2015 84 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Wilton Street Address 32 Vincek lane
0 Manner of Death LE Natural Cause O Accident Homicide C Suicide 0 Undetermined Pending
Circumstances LI Investigation
at Medical Certifier Name Title
John Mongan MD
Address
6 Medical Park Drive, Malta, NY 12020
Ziii Death Certificate Filed District4ig9r v Register fiber
City, Town or Village Wilton 'I
Pi Date Cemeteryor Crematory •
Entombment Pine View Crematory
Address
ECremation Queensbury, NY
Date Place Removed
Z R--.
Removal and/or Held
and/or Address
Hold
Date Point of
at Q Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Niii
si Q Reinterment Date Cemetery Address
€ Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
iiiii Address
402 Maple Ave. , Saratoga Springs, NY 12866
s< Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
i. Address
M
( Permission is hereby granted to dispose of the human remain described above as indicated.
GL
Date Issued Registrar of Vital Statistics ixL -vi c_(6000
n'�,C 1-
in (signature)
District Number ,L�6(q Place Wilton , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 r)
Date of Disposition �ZAI/$' Place of Disposition ,Fitt L Ctr ,«—mckr
(address)
Ill
fa
fr (section) (lot num r (grave number)
ciName of Sexton or Person in Charge of remises 4,. ,_ w r
z Tease print) •
W. Signature �`/� Title rR
(over)
DOH-1555 (02/2004)