Swain, Burke 19Fr
Y
NEW YORK STATE DEPARTMENT OF HEALTH �a
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Burke A. Swain Male
Date of Death Age ' If Veteran of U.S. Armed Forces,
May 6,2013 79 War or Dates Korean
F_ Place of Death Hospital, Institution or
�Z City, Town or Village Johnsburg I Street Address 7 Durkin Road
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
ILI Circumstances Investigation
Q Medical Certifier Name Title
Daniel Sooriabalan
Address
m11
Death Certificate Filed District Number Register Number 9
City, Town or Village Johnsburg 5655
❑Burial Date Cemetery or Crematory
El Entombment May 8,2013 Pine View Crematory
Address
0 Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
0 and/or Address
Hold
V)
0 Date Point of
N 1 1 Transportation Shipment
p by Common Destination
Carrier
1 1 Disinterment Date 1 Cemetery Address
Reinterment Date Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
Ct
G.
Permission is hereby granted to dispose of the human rem in escribe ove as indicated.
Date Issued OJJ &'i/o?�(3 Registrar of Vital Statistics i�� Clog
(signature)
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ul '%Date of Disposition 5- 3 Place of Disposition -'i�, C"u.r
2 (address)LLI
CO
(section) of number) (grave number)
Name of Sexton or Perso in Charge of Premises f'i'
Z f�, please print)LU
K
Signature A- Title C t t.04
(over)
DOH-1555 (02/2004)