Fox, Timothy Joseph 4 ,0
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records ''
Name First Middle Last Sex
Timothy Joseph Fox Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/26/2023 71 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Johnsburg Town Street Address 3853 State Route 8,Johnsburg Town,New York 12886
pManner of Death 0 Natural Cause ❑Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
a Jaime Bickford DO
Address
315 S.Manning Boulevard,Albany,New York 12208
Death Certificate Filed Town Of Johnsburg District Number Register Number
City,Town or Village 5655 3
Burial Date Cemetery,Crematory or Facility Name
01/27/2023 Pine Vew Crematorium
Entombment Address
Cremation Queensbury Town,New York
['Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
NQ
a Date Point of
(O Transportation
5 by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
pReintermentDate Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdemiott Funeral Home Inc 00141
Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
a Address
CC
W
13' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/26/2023 Registrar of Vital Statistics jean Comstock(E(ectronicalrySigned)
(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:
Z
W Date of Disposition tg e.g }�, ,,,� U,` „�
�3 Place of Disposition Crj1a r,{
2 (address) J
WI
It (sections ,�(lotin�um r) (grave number)
8 Name of Sexton or Person in Charge of mise ,4Ymd/4� Vier
Z / (p/ease print)
IliSignature L Title O iPS".t;
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ` r Fz : delivered on , 20
Pine View Cemetery Representing the'funeral home named on burial permit
Official Funeral Directors Reg.or License#