Knickerbocker, Vemis -0103)
NEW YORK STATE DEPARTMENT OF HEALTH] •�.,,: ,�!Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Vemis Ray Knickerbocker Male
1.1 Date of Death Age If Veteran of U.S. Armed Forces,
12/28/2018 88 Years War or Dates
r Place of Death Hospital, Institution or
City, Town or Village Johnsburg Town Street Address Elderwood at North Creek
Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
James Hindson MD
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
City,Town or Village North Creek 5655 35
=y_❑Burial Date Cemetery or Crematory
12/31/2018 Pine View Crematorium
Li Entombment Address
®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or
Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
�J.
t Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
y Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/30/2018 Registrar of Vital Statistics 7(atlil en C.Lorah(E(ectron caltySigned)
(signature)
District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
` Date of Disposition / 3l-t y Place of Disposition P: 4 orY
(address)
(section) (lot number) (grave number)
?tw Name of Sexton or Person in Charge of Premises 1-el pe y Seaif' S
(please print)
4
Signature Title Cif t,/(14.o r
(over)
DOH-1555 (02/2004)