Columbus, John NEW YORK STATE DEPARTMENT OF HEALTH 6(v
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John A. Columbus Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 8,2013 78 War or Dates Korean
t�-, Place of Death Hospital, Institution or
City, Town or Village Newcomb Street Address 5397 State Route 28N
ri Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
ui Medical Certifier Name Title
Kevin P.Bolan
Address
4 Santanoni Drive,Newcomb,NY 12852
Death Certificate Filed District Number Register Number
City, Town or Village Newcomb (66 2-
El Burial Date Cemetery or Crematory
❑Entombment October 14,2013 Pine View Cemetery
Address
❑x Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
w
O Date Point of
NTransportation 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
1. Remains are Shipped, If Other than Above
Address
tU
Permission is hereby granted to dispose of the human remains describe ov: . - indicated.
Date Issued /6- q—3 Registrar of Vital Statistics A_CW(1 / et. _
(signature)
District Number 133.9 Place Newcomb
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition ID/3113 Place of Disposition 4,7,4UQt,„ ( {or r„_
W (address)
co
O (section) (lot number (grave number)
pName of Sexton or Person in Charge of Premises ,,.-)1 L., .,,,ff
'Z it
print)
Signature 4-- �� Title Cy)E,t+�110
L
(over)
DOH-1555 (02/2004)