Cook, Christopher NEW YORK STATE DEPARTMENT OF HEALTH s w J "l Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Christopher Vincent Cook M
.../ : : Date of Death 0 9/1 1 /2 01 3 Age If Veteran of U.S. Armed Forces,
60 War or Dates 1 972-1 976
Place of Death Hospital, Institution or
ffi 73 Main Street -�
City, Town or Village Argyle Street Address t t Manner of Death ®Natural Cause C]Accident 0 Homicide Suicide � Undetermined nding
wCircumstances Investigation
til
tu Medical Certifier Name Title
f1 Michael Sikirica MD
Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register Number
, City, Town or Village Argyle 5720
ElBurial Date Cemetery or Crematory
09/13/2013 Pineview Crematory
:<:❑Entombment Address
`;;]Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
7 Removal and/or Held
and/or Address
it: Hold
4
0 Date Point of
0
Transportation Shipment
byCommon Destination
G Carrier
0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
'i< Permit Issued to Registration Number
«< Name of Funeral Home MB Kilmer Funeral Home 01 077
li' Address
123 Main Street Argyle,NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
iC
I>
; Permission is hereby granted to dispose of the hum �ma s described ve as indicated.
?j
9
«> Date Issued //a// Registrar of Vital Statistics
gg (signature)
<` District Number 5-7,72) Place ,a0
``':i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F��l'� Date of Disposition 4I(311:� Place of Disposition ii�+ ,.....
i ► (address)
in
til
CC (section) A
(lot number) #� (grave number)
Ci Name of Sexton or Pers in Charge of Premises lit, 3 iti
( e print)
W.
Signature _ Title (liC Any&
(over)
DOH-1555 (02/2004)