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VanDerwarker, Daniel O.
) # 263 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Daniel O.VanDerwarker Male Date of Death Age If Veteran of U.S.Armed Forces, -' 03/14/2023 76 Years War or Dates 1_4 Place of Death Hospital,Institution or Z City,Town or Village Thurman Town Street Address 592 High Street,Thurman Town,New York 12810 p Manner of Death Z Natural Cause Accident El Homicide OSuicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title Ca Lynn Keil PA Address 9 Carey Road,Queensbury Town, New York 12804 Death Certificate Filed Town Of Thurman District Number Register Number City,Town or Village 5659 2 Burial Date Cemetery,Crematory or Facility Name 03/20/2023 Pine View Crematory _Entombment Address ©Cremation Queensbury Town,New York JJDonation Z Date Place Removed O 0 Removal and/or and/or Held H Hold Address N 0 n. Date Point of U) Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address 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 Remains are Shipped,If Other than Above Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/20/2023 Registrar of Vital Statistics Cynthia R xyde(ECectronically Signed) (signature) District Number 5659 Place Town Of Thurman I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: --'7 W Date of Disposition 3 J ZI L l3 Place of Disposition rf !�. rit.Jn-- u ,., 2 (address) W NCC (section) i (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises r,, �`-- I R W (lease print) Signature 0 ��Title t rdIt 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# 1