York, Kyle 1 1611,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firs/ MiddleD. York Sexmyle Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/06/2013 59 years War or Dates
f- Place of Death Hospital, Institution or
W City, T�SX440 Al! Saratoga Springs Street Address Saratoga Hospital
C Manner of Death❑Natural Cause Ei Accident D Homicide El Suicide riUndetermined 0 Pending
W Circumstances Investigation
La Medical Certifier Name Title
Q Michael Sikirica Md
Ackg road St., Waterford, N Y
Death Certificate Filed District Number Register Number
City, T S)br)VAPW Saratoga Springs 4501 462
ID Burial Date Cemetery or Crematory
11/08/2013 Pineview Crematory
['Entombment Address
ElCremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
2❑and/or Address
F" Hold
IA
O Date Point of
th❑Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
le Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
ir
fI
C Permission is hereby granted to dispose of the human rema' d abye indicate .
Date Issued 11/07/2013 Registrar of Vital Statistics cri �
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
P II /ylt3 Di
sposition Date of Disposition Place of Dis osition gmOW-) G.w ar,t,._
2 (address)
UI
LO.
(section) (lot number) c (grave number)
tiName of Sexton or Person in Charge of Premises gi.» r''^in
A----
(p/e se print)
��Signature 4 Title Cvlcd
(over)
DOH-1555 (02/2004)