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Speenburgh, James William . . .. it- To NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James William Speenburgh Male Date of Death Age If Veteran of U.S.Armed Forces, 01/18/2021 63 Years War or Dates F— Place of Death Hospital,Institution or WCity,Town or Village Chester Town Warren Street Address 378 Landon Hill Road,Chester Town Warren,New York 12817 p Manner of Death ©Natural Cause 0 Accident EI Homicide El Suicide El Undetermined El Pending VCircumstances Investigation EMedical Certifier Name Title David Slingerland MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Chestertown 5652 1 0 Burial Date Cemetery,Crematory or Facility Name Q1/20/2021 Pine View Crematorium EI Entombment Address 0 Cremation Queensbury Hamlet,Warren,New York Donation 2 Removal Date Place Removed —.. and/or and/or Held Hold Address 0 CL Date Point of f/) L j Transportation lr3 by Common Shipment Carrier Destination i, Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom p— Remains are Shipped,If Other than Above a Address CC a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/19/2021 Registrar of Vital Statistics Windy Conway(ECectronica1tySigned) (signature) District Number 5652 Place Chestertown, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— W Date of Disposition J Zl 2I Place of Disposition FAL2 address/ W Cr (section) lot number) (grave number) 8 Name of Sexton or Person in Charge of Premi s L tmi lirt Z /pleas*print, W c Signature �nature G—� Title a` DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014 `4 Receipt Human remains of /j delivered on , 20 Pine View Cemetery Representing"-the funeral home named on burial permit Official Funeral Directors Reg.or License#,/),