Barber Sr, John W It,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John M. Barber Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces, NO
F January 15, 2015 67 War or Dates
2 Place of Death Hospital, Institution or
W City,Town, or Village Saratoga Springs Street Address Saratoga Hospital
0 Manner of Death ®Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
o Medical Certifier Name Title
W Robert Wang MD MD
0 Address
Saratoga Hospital
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs /1 5 f7[ 3---?
❑Burial Date Cemetery or Crematory
January 21, 2015 Pineview Crematorium
❑Entombment Address
q El Cremation Town of Queensbury Queensbury, NY 12804
Date Place Removed
0 ❑ Removal and/or Held
- and/or Address
Hold
0 Date Point of
0 ❑Transportation Shipment
Da by Common Destination
Carrier
Date Cemetery Address
o ❑Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
re• Remains are Shipped, If Other than Above
W Address
O.
Permission is h eby ranted to dispose of the human rem ' e =119 e-a indicate .
7
Date Issued t Registrar of Vital Statistics ``, �
(signature)
District Number Li 60\ Place Saratoga Springs,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 01/21/2015 Place of Disposition Pineview Crematorium
2 (address)
W
vi
D (section) (lot number) (grave number)
ZName of Sexton or Person in Charge of Premises (4tj�apL— Se»M
W (please print)
Signature k Title [GLKepv
(over)
DOH-1555 (02/2004)