TenEyck, William Edward , #(611
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NEW YORKSTATE DEPARTMENT OFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
William Edward TenEyolc Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/30/2022 62 Years War or Dates
1.. Place of Death Hospital,Institution or
Z gCity,Town or Village Johnsburg Town Street Address 39 Oven Mountain Road,Johnsburg Town,New York 12843
Mannerof Death ED Natural Cause [accident ElHomicide Suicide DUndetermined ❑Pending
W
U Circumstances Investigation
WW Medical Certifier Name Title
CI
Christine Roe NP
Address
3 Crossing Boulevard,Clifton Park Town,New York 12065
Death Certificate Filed Town Of Johnsburg District Number Register Number
Cit ,Town or Village 5655 21
Burial Date Cemetery,Crematory or Facility Name
081b3/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
4:1❑Removal Date Place Removed
F and/or and/or Held
— Hold Address
CA
fZ Date Point of
CO Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
1LL❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
CC
If
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/03/2022 Registrar of Vital Statistics fears.'Coms'toc€( fctr Sjiwd)
/signature/
District Number 5655 Place Town Of Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: oo',,
WDate of Disposition gj31 ZZ Place of Disposition -at r,-L. _
a (address/
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8 (section) (� (lot number) (grew number)
Name of Sexton or Person in CI
Premises //i M L 1/44 tit
W Signature s=G� Title (FlE1� 2
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DOH-1555(07/18)p t of 2
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Public Health Law Sec. 4145(2b)
Receipt
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1
1 Human remains of delivered on , 20
1
1
1 Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# '