Knickerbocker, Delbert t 1176I
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Delbert W Knickerbocker Male
Date of Death Age If Veteran of U.S. Armed Forces,
8/22/2018 78 War or Dates
i- Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 44 Willowbrook Road
pManner of Death Natural Cause n Accident n Homicide n Suicide n Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Thomas Portuese,MD
Address
100 Broad Street,Glens Falls NY 12801
De- - -- ' icate File District Number Register Number
Cit , Town • Village e
tup
-1 9c n. � .0
❑Bun- Date Cemetery or Crematory
Entombment August 24, 2018 Pine View Crematory
11 Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
Cl) Date Point of
O. n Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Sir eton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Dispo ition or to Whom
I- Remains are Shipped, If Other than ,Above
2 Address
W
O. Permission is hereby granted to dispose of the human re ns described'� e s indicated.
Date Issued l 2M I, a Registrar of Vital Statistics aC„,-._5%( t a - --
_____, (signature)
District Numbercoc--) Place D l > £
.) C....
I certify that the remains of the decedent identified above were disposed fin accordan a with this permit on:
uJ Date of Disposition s jI Ii Place of Disposition .?",,11,�.• �( t Sri.
(address)
W
CO
CL
(section) p (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises L Itr• f Li1�
`LI
Z (ple se print)
JSignature r Title alf 41 i0t9t-
(over)
DOH-1555(02/2004)