Vanderwarker, David NEW YORK STATE DEPARTMENT OF HEALTH t 13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Daivd D. Vanderwarker Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/20/2013 74 War or Dates Vietnam
Place of Death Hospital, Institution or/2 j?,,r �r�u, A7
City, Town or Village Chesterta Street Address Deceased's Residence
W' Manner of Death atural Cause Accident 0 Homicide Suicide Undetermined Pending
U. Circumstances Investigation
Q Medical Certifier Name-r--�� �?
U �
Address ,
Death Certi icate Filed j-z".eDistrict Number Register Number
City,Town or Village �/ ...T/.'`7 _ `� �` �j-/
❑Burial Date Cemetery Cremato�' ,
02/21/2013 h=( t/-1 1 (`u a.`dl/v 4,,
0 Entombment Address '
®Cremation ✓a 'II , CXG�-�' �/✓.67-..........-6--/V/.2_,,i-fe,
Date Place Removed
z El Removal and/or Held
and/or Address
E Hold
0' Date Point of
Transportation , Shipment
ly; by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
re
O. :::__/9b/
. Registrar of Vital Statistics
(sign re)
District Number c�,� Place Q9 (ite.,,, --_,,,_
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W'; Date of Disposition 2 11-c3 Place of Disposition 'F 't.41.4 ; ` epN.,
(address)
tif
c (section) X (lot number) (grave number)
CI Name of Sexton or Perso in Charge of remises iS enr,4t
Z (pl se print)
111 Signature Title CvP'T
(over)
DOH-1555(02/2004)