Whipple, Jordan NEW YORK STATE DEPARTMENT OF HEALTH 11
Vital Records Section Burial - Trans!' ermit
Name First Middle Last Se
Jordan Scott Whipple Male
Date of Death Age If Veteran of U.S. Armed Forces,
4-1 1 -1 3 2 7 War or Dates NO
Place of Death Ttl. of Moreau Hospital, Institution or Nolan Rd.
City, Town or Village Street Address
Manner of Death Natural Cause El Accident El Homicide Qx Suicide nUndetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Sikirica MD
Address
50 Board St. Waterford, NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village Tn. of Moreau 4/5-6,? Y
0 Burial Date Cemetery or Crematory
4-15_13 Pine View Crematory
❑Entombment Address
®Cremation 21 Quaker Rd. QuePnsbury, NY 12804
Date Place Removed
1-1 Removal and/or Held
and/or Address
Hold
Date Point of
I I Transportation Shipment
by Common Destination
Carrier
11 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Re istration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01 078
Address
136 Main St. South Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem ' s described above as ' icated.
Date Issued 4-15-13 Registrar of Vital Statistics A.
(signature)
District Number L/j 202 Place Tn. of Moreau
I certify that the remains of the decedent identified above were disposed of in accordancewith this permit on:
/
Date of Disposition q-l r-t3 Place of Disposition e,►()k-J C-rv{" v,.-
(address)
(section) It number) (grave number)
Name of Sexton or Person i Charge of Pr miser nt, lH►-411-
(please tint)
9
Si nature /�� Title CefiW.)t,
(over)
DOH-1555 (02/2004)