Burke, James NEW YORK STATE DEPARTMENT OF HEALTH
A �s 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Patrick Burke Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 2, 2015 67 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death j IL Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 1-7 Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Sean Bain, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number i Registe` nar
City, Town or Village Glens Falls
❑Burial Date Cemetery or Crematory
July 6, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued -I /6/ Registrar of Vital Statistics W C�-AJ Li1/4.1/1/4-/-51-Agr
(signature)
District Number S.&'o j Place 6 CO3_,,,,S VG t S � wy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/06/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numbed,.. (grave number)
Name of Sexton or Person • Cha a of Premises /w --)erf'
( lease print)
Signature Title
(over)
DOH-1555 (02/2004)