White, John NEW YORK STATE DEPARTMENT OF HEALTH 4 -N
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John M. White Male
':: Date of Death Age If Veteran of U.S. Armed Forces,
01/06/2013 61 years War or Dates
Place of Death Hospital, Institution or
City, c y�ri j�ory Saratoga Springs Street Address Saratoga Hospital
0 Manner of Death Natural Cause D Accident D Homicide D Suicide D Undetermined D Pending
it : Circumstances Investigation
tu Medical Certifier Name Title
G? Micbael Sikirica Md
Address
50 Broad St., Waterford, N Y
Death Certificate Filed District Number Register Number
City, Rimogyk4§9e Saratoga Springs 4501 15
[]Burial Date Cemetery or Crematory
DEntombment 01/08/2013 Pineview Crematorium
Address
;::;;]Cremation Queensbury N Y
Date Place Removed
• Removal and/or Held
▪ and/or Address
0 Hold
to
O Date Point of
❑Transportation Shipment
C3 by Common Destination
Mi Carrier
D Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
< Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
iAi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
2
tti
CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/08/2013 Registrar of Vital Statistics
gi
(signature)
District Number 4501 Place Sarato a S rin s
I certify that the remains of the decedent identified above w dis osed of in accordance with this permit on:
tit Date of Disposition 1_40-13 Place of Disposition g41...Cvdoftt
(address)
ILA
Eli
11 (section) (lot number) } (grave number)
Name of Sexton or erson in Cha a of Premises , rci S'iI
z (pie se print)
Signature Title C+ F� it
(over)
DOH-1555 (02/2004)