Decker, Merrill p
lr
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Merrill F. Decker Male
Date of Death I Age If Veteran of U.S. Armed Forces,
February 9,2012 78 War or Dates
Place of Death Hospital, Institutiory dirondack Tri-County Health Care
'Z City, Town or Village Johnsburg Street Address Center
p Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Thomas Warrington
Address
HHHN,Johnsburg,NY 12843
Death Certificate Filed District Number I Register Number
City, Town or Village Johnsburg 5655
❑Burial Date Cemetery or Crematory
February 13,2012 Pine View Crematory _
D Entombment Address
E1 Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
Hold
U)
O Date Point of
Transportation Shipment -
a by Common Destination
Carrier •
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
Address
W — - --- -
a
Permission is hereby granted to dispose of the human remai�sdriboy s indicated.
Date Issued a//a o2 d!d Registrar of Vital Statistics LTV {{,,�(��✓✓�GL�O►-�
(signature)
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1` e"
tu Date of Disposition S, lc;Z Place of Disposition ,.� i
(address)
cn
(section) /� (lot numt>e4` (grave number)
pName of Sexton or Person in Charge f Premises
(please print)
W r
Signature .-( Title C e ti1l'(il(t.
(over)
DOH-1555 (02/2004)