Burke, John NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Francis Burke Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 2, 2013 67 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Saratoga Springs Street Address Saratoga Hospital
a Manner of Death I XI Natural Cause n Accident r I Homicide n Suicide Undetermined J Pending
Circumstances Investigation
uj Medical Certifier Name Title
0 Heather Madigan MD
Address
211 Church Street, Saratoga Springs, New York 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 Z
El Burial Date Cemetery or Crematory
May 3, 2013 Pine View Crematorium
❑Entombment Address
CI Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
and/or Address
E Hold
N
O Date Point of
05 I I Transportation Shipment
p by Common Destination
Carrier
r7 Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc. 00281
Address
68 Main Street, P.O. Box 67, Hudson Falls, New York 12839
Name of Funeral Firm Making Disposition or to Whom
f— Remains are Shipped, If Other than Above
• Address
Lu
Permission is her by ranted to dispose of the human remains de =alaier indicat
Date Issued 3 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tu• Date of Disposition 'c-7-5 Place of Disposition s C rty+v
W
(address)
co
pcc (section) {lot number) (grave number)
Name of Sexton or Person in Charge of Premises (ii �,,n►(
Wlease print)
Signature Title
(over)
DOH-1555 (02/2004)