Butler Jr, Walter NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
malp-
Wa I tax 'Fir
[ Date of Death Age If Veteran of U.S. Armed Forces,
March 18 19 War or Dates WW-II
Place of Death Hospital, Institution or
Town bDNW Johnsburg Street Address No. Creek Health Center
Manner of Deatatural Cause Accident Homicide 0 Suicide Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Daniel Way., M n-
Address
No. Creek Health Center No. Creek N.Y. 12853
Death Certificate Filed District Number Register Number
-y Townes Johnsbur 5655
Date Cemetery or Crematory
❑Burial March 20, 1997
Address Queensbury, N.Y. 12804
Cremation
Date Place Removed
Removal and/or Held
... and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
<: Name of Funeral Home Alexander Funeral Home 00017
Address
Rt. 28 North River N.Y. 12856
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Al
Permission is hereby granted to dispose of the human r mains descri d above as indicated.
Date Issued 3/19/97 Registrar of Vital Statistic
(signature)
District Number 5655 Place Johnsburg Town Clerk's Office, No. Creek, N.Y. 12853
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 � �` !�/i�4esf W (address)
LU
(section) (lot Dumber) (grave number)
GName of Sexto r Person in Charge of P emises o �— C�i��./� AM/ I
(please print) !
tU Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61