Farrell Jr, John t . a ttm
NEW YORK STATE DEPARTMENT OF HEALTH �'�
Vital Records Section Burial - Transit Permit
`. Name First Middle Last Sex
John P. Farrell,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
=7 December 27,2013 67 War or Dates
,,, Place of Death Hospital, Institution or
City, Town or Village Thurman Street Address 49 Athol Rd.
s Manner of Death I Xi Natural Cause I I Accident I I Homicide Suicide Undetermined ]Pending
Circumstances Investigation
g Medical Certifier Name Title
P: Mark M.Hoffman
Address
Park,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Thurman 5659r
❑Burial Date Cemetery or Crematory
0 Entombment December 30,2013 Pine View Crematory
Address
Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I (Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
coa.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street, Warrensburg, NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
N° Address
,
k Permission is her by ranted to dispose of the human ains described ab a as in•icated.
Date Issued Registrar of Vital Statistics A_,7 �/
(signs Cre)
District Number 5659 Place Thurman
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tu Date of Disposition [ / j -g Place of Disposition
� ,s„9 C'rcitirt�.
W (address)
co
re
(section) (lot number)/ (grave number)
p Name of Sexton or Person in harge of Premises �i) +. t
Z (p ase print)
u1 Signature L A -- Title Cet q((t,
(over)
DOH-1555 (02/2004)