Forkey, Sherman NEW YORK STATE DEPARTMENT OF HEALTH 4 '', f 5-1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sherman D. Forkey Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/22/2015 73 years War or Dates
Place of Death Hospital, Institution or
W City, 1-044X9WCX Saratoga Springs Street Address 107 Van Dam St
p Manner of Death ,Natural Cause 0 Accident ❑Homicide 0 Suicide ri❑Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
L Robert Nielson, M D �1 D
Address
3044 Route 50, Saratoga Springs, N Y 12866
Death Certificate Filed District Number Register Number
City, TovXXXXViiiMX Saratoga Springs 4501 45
.El Burial Date Cemetery or Crematory
❑Entombment 01/23/2015 Pine View Cemetery
Address
(cremation Queensbury N Y
Date Place Removed
Z ❑Removal and/or Held
• and/or Address
C. Hold
U)
O Date Point of
❑Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Care, Inc. 00364
Address
402 Maple Avenue, Saratoga Springs, N Y 12866
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
Z Address
tic
f't` Permission is hereby granted to dispose of the human remains e bov in icated.
Date Issued 01/22/2015 Registrar of Vital Statistics '' �`
(signature)
District Number 4501 Place Saratoaa Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Cr-,A.,'Date of Disposition I /Zb llr' Place of Disposition fM �,, ;,�,
2 (address)
ill
CC (section) f (lot number) (grave number)
Name of Sexton or Person . Char of Premises
4%414-
2. I (please print)
tti
Signature Title L tie
(over)
DOH-1555 (02/2004)