Walkup, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Michael Walkup Male
• Date of Death Age If Veteran of U.S. Armed Forces,i G (y
January 16, 2014 65 War or Dates l t �" ` ` `1 Z
Place of Death Hospital, Institution or
_ City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death E Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Darci Ann Gaiotti-Grubbs, M.D Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
- City, Town or Village Glens Falls S-G O i 3 3
❑Burial Date Cemetery or Crematory
January 21, 2014 Pine View Crematory
• e ❑Entombment Address
'. ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
• and/or Address
Hold Quaker Road Queensbury,NY 12804
Date Point of
❑Transportation Shipment
by Common Destination
a Carrier
,. ❑ Disinterment
Date Cemetery Address
El Reinterment
Date Cemetery Address
• Permit Issued to Registration Number
_
`i• ' Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
., Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
rr Permission is hereby granted to dispose of the human remains described above as indicated.
7 Date Issued II ` i Registrar of Vital Statistics c .Y.Q ujJ
(signature)
District Number 5.60 / Place 6 S cu. l\ s / N U PT i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/21/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot n mber) C (grave number)
Name of Sexton or Person in arge of Pre ises Anal. �" `�1h0�`1'
le print)
�� (P P )
z Signature Title �tEl�Ai ,
g
(over)
DOH-1555 (02/2004)