Loading...
Haley, John Christopher 1-l ) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John Christopher Haley Male Date of Death Age If Veteran of U.S.Armed Forces, 02/22/2021 80 Years War or Dates 1960-1980 p. Place of Death Hospital,Institution or WCity,Town or Village Petersburgh Town Street Address 99 Smith Road, Petersburgh Town, New York 12138 p Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide n Undetermined Pending W U Circumstances Investigation W Medical Certifier Name Title 0 Allen Hutcheson MD Address 16 Danforth Street,Hoosick Falls Village,New York 12090 Death Certificate Filed District Number Register Number City,Town or Village Petersburgh Town 4157 4 Burial Date Cemetery,Crematory or Facility Name 02/24/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York Donation Removal Date Place Removed and/or and/or Held f- Hold Address N 0 tL Date Point of to Li Transportation G by Common Shipment Carrier Destination Disinterment Date Cemetery Address Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077 Address 123 Main St,Argyle,New York 12809 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 2 Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/24/2021 Registrar of Vital Statistics Deidra A Michaels(Electronically Signed) (signature) District Number 4157 Place Petersburgh Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 2,-1_14 u121 Place of Disposition P/h ev 1 ,I cre,w1c7e,1 IJ( (address) W CC N (section) A l (lot number) (grave number) 0 Name of Sexton or P n in C arge of Premises CA `' ��' v Z please print) I, W Signature Title G DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) O1 5 8 Receipt t Human remains of delivered on , 20 ,' ) , Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#