Devendorf, Arthur NEW YORK STATE DEPARTMENT OF HEALTH # s-c-?
Vital Records Section % Burial - Transit Permit
Name First Middle Last Sex
Arthur Devendorf Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/30/2014 90 War or Dates World War II
Place of Death Hospital, Institution or
u City, Town or Village Pottersville Street Address Deceased's Residence
Manner of Death m Natural Cause 0 Accident ElHomicide 0 Suicide ElUndetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name R1 Title
40 Lynn M. Keil,
„,,,
Address
6223 St Rte 9 Chestertown, NY 12817
Deat ificate Filed District Number Register Number
City TowRor Village //�/ u Cc2-Yl 56S
0 Burial Date Ce etery or cremator
09/02/2014 $n--" 1%c'u/ C/26 l u/C3.„/d,,..,
0 Entombment Address L
°:®Cremation i/t� . 7 4, O'' �(�'C� USX r/�/� �� . �1 'O/
Date Place Removed
- 0 Removal and/or Held
and/or Address
Hold
tf Date Point of
IDTransportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
. , Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
, ,, Address
y rt 9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
Address
' . Permission is hereby granted to dispose of the human re ins described above as indicate .
A - Date Issued ff/ i] I`f Registrar of Vital Statistics �L. A_ �`
/ / (sio7,1,„
e)
District Number 5"(0 5 LI Place r£ -Li f-7i J 6j t&n.J)
»p ,. I certify that the remains of the decedent identified above were disposed of ino accordance with this permit on:
Date of Disposition °1/3//y Place of Disposition eF
of 1/-• f,i^
(address)
(section) f�(iot number) r (grave number)
Name of Sexton or Person in Charge of Premises ` ''14?L S0"n '
(please print)
Signature A Title C1 ff mft1'
(over)
DOH-1555(02/2004)