Hoertkorn, Steven I/ y/c
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Steven Charles rtkorn Male
Date of Death Age If Veteran o .S. Armed Forces,
May 17 2015 69 War or Dates n/a
I Place of Death Hospital, Institution or
tit_ City, Town or Village glens Falls, NY Street Address 21 Bay Street, Apt 210
C Manner of Death❑Natural Cause 0 Accident El Homicide EISuicide ,mg Undetermined FlPending
tti Circumstances Investigation
W Medical Certifier Name Title
0 Timothy Murphy, Coroner
Address
Glens Falls, NY '
it Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls, NY 5601 2 S
OBurial • Date Cemetery or Crematory
June 3, 2015 Pine View Crematory
['Entombment Address
::;Cremation Queensbury, NY '
Date Place Removed
2 ❑Removal and/or Held
and/or
Address
l' Hold
tel
0 Date Point of
0 Li Transportation Shipment
0 by Common Destination
ig Carrier _
iEl Disinterment Date - Cemetery Address
,iiiReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd Queefury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tr
tL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6 12 1 i 5 Registrar of Vital Statistics (A)-
(signatur
District Number 5 bQ 1 Place 6 (2M 5 ca \\S , 1,J. \)
is I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 4/5/ic Place of Disposition IA� Ci-4*---
2 (address)
I
CC (section) A(lot number) (grave number)
ci Name of Sexton or Person in Char a of Premises i"'`ri` �/""`
z Z (pl se print)
: Signature Title `"`✓met
(over)
DOH-1555 (02/2004)