Mecklenburg, Kristoph t s li It QV
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kristoph J. Mecklenburg Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/08/2014 19 War or Dates
1 Place of Death Hospital, Institution or
Z City, Tewn-er-Village- Glens Falls Street Address Glens Falls Hospital
lAiManner of Death 0 Natural Cause 0 Accident 0 Homicide E Suicide Undetermined Pending
Circumstances Investigation
til Medical Certifier Name Ttl
c . : � � { (I 1
' ,.r-s Iiita
milks t` 1
`< Death Certificate Filed District Number R�r Number
/ Regist
or Village l�kr7Sh"1/7Py ,56i1 /17
❑Burial Date Cemetery or Crematory
04/09/2014 Pine View Crematory
k Entombment Address
Eii EtCremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
Removal and/or Held
....+ and/or Address
i=" Hold
O Date Point of
3 0 Transportation Shipment
G by Common Destination
Carrier
hi 0Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
0 LiPermit Issued to Registration Number
Name of Funeral Home Stuart-Fortune-Keough Funeral Home 01640
iN Address
24 Cliff Ave. Tupper Lake, NY 12986
iiil Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
1r
Ili
1 Permission is hereby granted to dispose of the human remains described above as indicated.
'_ Date Issued y J q f / Lf Registrar of Vital Statistics (i.) Ck-A))-(4Z- W
(signature)
District Number S of Place 6(e s i.la/V
"' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lif• Date of Disposition ((MIN Place of Disposition ?�� 6-,,
4r,,�
(address)
iii
CC (section) (lot number) (grave number)
et Name of Sexton or Perso in Charge of Premises f+1 en
2 ( ease print)
• Signature taii
Title CQi�;rht4
1
ire
(over)
DOH-1555 (02/2004)