Falk, John NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
John E. Falk M
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Date of Death Age If Veteran of U.S.Armed Forces,
11 17 93 72 War or Dates WW II
. Place of Death Hospital,z sl, Institution or '
>U# City,Town or Village Minerva Street Address Irishtown Rd.,Olmstedville,NY
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W Manner of Death.. Natural Cause Accident Homicide Suicide Undetermined Pending
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W -
Circumstances Investigation
Medical Certifier Name Title
p ]Dr. Way MD
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Address
North Creek,NY
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Death Certificate Filed District Number Register Number
» City,Town or Village Minerva 1557
Date Cemetery or Crematory
❑Burial 11-22-93 Pine View Crematory
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...Address ....
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Cremation Queensbury,NY
Z Date Place Removed
0,, ❑ Removal and/or Held
H and/or Hold ...Add r r...:... .: .............................. .
A ess _.:::..
O............................... .................:... ....... :::.:.....:
a Date Point of _:. ...:..... ...._::::. .
cn Transportation by Shipment
p Common Carrier ........
Destination
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Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address El
Permit Issued to Registration Number
Name of Funeral Firm Alexander-Baker FH 00018
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Address
Warrensburg,NY. . :
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4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, H Other than Above
......... ..................................................... .......... . .Address
::ut>
Permission is hereby granted to dispose of the hum remains de rib above a indicated.
Date Issued 11-19-93 Registrar of Vital Statistics z2f1 Lc
(signature)
District Number 1557 Place T/O Minerva,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition —/ Place of Disposition
2 (address)
Lu
Cn (section) (lot number) (grave number)
cce I
p Name of Sexton Person in har a of Pre ises
Z (please print)
W Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61