Evans, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
JOHN D EVANS IV
Date of Death Age 1 If Veteran of U.S. Armed Forces,
AUG 4, 1 9 9 7 58 War or Dates
Place of Death Hospital, Institution or
City, Town or Village SARATOGA SPRINGS Street Address SARATOGA
Manner of Death�Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
TIMOTHY BROOKS MD
Address
211 'CHUR
Death Certificate Filed District Number,/ Register Num�O
City, Town or Village SARATOGA �`..ff
Date Cemetery or Crematory
❑Burial 8/5/97 PINEVIEW CREMATORY
Address
®Cremation QUEENSBURY NY
Date Place Removed
Z ❑Removal and/or Held
0 and/or Address
Hold
O Date Point of
N❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home TUNI SON FUNERAL HOME 01937
Address
105 LAKE AVE. SARATOGA SPRINGS NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
permission is he eb/y granted to dispose of the human remains escri ed above a icated.
Date Issued / F Registrar of Vital Statistics
(si
District Number Place PUBLIC SAFTY OF SARATOGA SPRINGS
r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- {� I t ,n
z Date of Disposition Place of Disposition /_ / /ll� l//.FkJ G�i�/��/aA(r�N 1
W (address)
Uj
W
(section) (lot mber (grave number)
GName of Sexto or Person in Charge of Premises ��&&�RD � �/ J
(please print)
W Signature Title' Q '
DOH-1555 (10/89) p. 1 of 2 VS-61