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Walker, William F Sr. # 1Z NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex William F.Walker Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 01/30/2022 68 Years War or Dates Place of Death Hospital,Institution or ILI City,Town or Village Fort Ann Town Street Address 1 Grey Goose Road, Fort Ann Town, New York 12827 Manner of Death ©Natural Cause 0 Accident D Homicide 0 Suicide D Undetermined D Pending Iii Circumstances Investigation w' Medical Certifier Name Title Ca Joseph Mihindukulasuriya MD Address 20 Murray Street,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Fort Ann 5754 5 ❑Burial Date Cemetery,Crematory or Facility Name Entombment 01/31/2022 Pineview Crematorium Address ' 0 Cremation Queensbury Town,New York 0 Donation ©❑ Date Place Removed Removal lf= and/or and/or Held U 5 Hold Address Date Point of 01 ❑Transportation (a by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01117 Address 18 George St Po Box 277,Fort Ann,New York 12827-0277 Name of Funeral Firm Making Disposition or to Whom i.. Remains are Shipped,If Other than Above X Address ir iti IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/31/2022 Registrar of Vital Statistics Barbara J Winchell (Electronically Signed) (signature) District Number 5754 Place Fort Ann, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /I Date of Disposition 2 1 l I 2t Place of Disposition ,�Q� / T` UJ Z (address) '"`" W `tl) Lr (section) 11 (lot number) (grave number) 8 Name of Sexton or Person in Charge yises 6 kt,i tpL 5�A4C' Z (pleale print) US efAlt Signature Title �� ii�IC DOH-1555(07/18)p 1 of 2 J15595 Public Health Law Sec. 4145(2b) 1 Receipt Human remains of delivered on , 20 } Pine View Cemetery Representing the funeral home named on burial Permit Official Funeral Directors Reg.or License# ' r