Eversman, Walter s' N. t
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Walter H. Eversman Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 4,2015 74 War or Dates 1959- 1961
" Place of Death Hospital, Institution or
o City, Town or Village Warrensburg Street Address 27 Third Ave.
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W; Medical Certifier Name Title
O Sarah Durkee RPAZ
Address
6223 State Route 9,Chestertown,NY 12817
Death Certificate Filed District Number Register Number /
City, Town or Village T/O Warrensburg 5660
❑Burial Date Cemetery or Crematory
February 6,2015 Pine View Crematory
Ell Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
zO Li Removal and/or Held
and/or Address
H Hold
N
O Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
}.=, Remains are Shipped, If Other than Above
Address
1
"' Permission is her by granted to dispose of the human escribed above as indicated.
Date Issued Registrar of Vital Statis ' s Q,41--,---(21C. n-ar�J
(signature)
District Number '; 60 Place T/O Warrensburg
I certify that the remains of the decedent identified above were disposed ofin accordance with this permit on:
w Date of Disposition 2,40//c Place of Disposition �A,v� cp,.
(address)
W
N
O (section) t
(lot nur) (grave number)
rribe
Q Name of Sexton or Person in Charge of Premises ,k
Z � lease print)
ua Signature G if s Title nuimiijf
(over)
DOH-1555 (02/2004)