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Everetts, Walter C
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Walter C Everetts Male Date of Death Age If Veteran of US.Armed Forces, 01/06/2024 76 Years War or Dates 1966-68 F. Place of Death Hospital,Institution or WCity,Town or Village Corinth Village Street Address 22 Saratoga Avenue,Corinth Village,New York 12822 p Manner of Death IZI Natural Cause ❑Accident ❑Homicide 0 Suicide n Undetermined ri Pending VCircumstances Investigation ILI G Medical Certifier Name Title John Pezzulo DO Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed Town Of Corinth District Number Register Number City,Town or Village 4553 1 EfBurial Date Cemetery,Crematory or Facility Name 01/09/2024 Pineview Crematory Entombment Address ©Cremation Queensbury Town,New York Donation Z a Removal Date Place Removed and/or ri and/or Held N Hold Address 0 Cl. Date Point of (I) Transportation p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom E.. Remains are Shipped,If Other than Above 2 Address CC W II' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/08/2024 Registrar of Vital Statistics Brenda L Penis(Electronically Signed) /signature) District Number 4553 Place Town Of Corinth I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- W Date of Disposition /-?-':zo 239 Place of Disposition P,„V IV9 c'v' C,rem w 4C,rY 2 (address) 1W CC (section) (lot number) (grave number) O Name of Sexton or Person in Charge of Premises J c('ri t,j 5 t t r-c.S z (please print) W Signature /. . . ` Title �Q Iv -1c c / DOH-1555(07/18)pi of 2 1m 7 8 3 .) 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#