O'Rourke, Patrick George „op loo
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Patrick George O'Rourke Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/12/2022 76 Years War or Dates
1— Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death X❑Natural Cause Accident El Homicide ESuicide InUndetermined riPending
W Circumstances Investigation
W Medical Certifier Name Title
Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 624
' Burial Date Cemetery,Crematory or Facility Name
12/19/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
Hold Address
n
d Date Point of
N Transportation Shipment
�j by Common
Carrier Destination
11 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/13/2022 Registrar of Vital Statistics Megan'ofn(E/ctrortcaf Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition (21 it 17Z Place of Disposition 1.AV
2 (address)
W
Q (section) dal
number) (grave number)
SName of Sexton or Person in Charge of Premises
Z (pl print)
W Signature Title J �e� 2
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#