Baker Sr, Glenn NEW YORK STATE DEPARTMENT OF HEALTH !
- � $ 3a1 Vital Records Section v Burial - Transit Permit
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Name First Middle Last Sex
Glenn F: 3 Baker, Sr. Male
A Date of Death Age If Veteran of U.S. Armed Forces,
Y April 18,2017 78 War or Dates
ix� Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
-c( Manner of Death X Natural Cause Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificate Filed District Number Register Number
.,;.;1 City, Town or Village b 0 1 2.3 p
❑Burial Date Cemetery or Crematory
April 20,2017 Pine View Crematory
❑Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
0 and/or Address
' Hold
Cl)
p Date Point of
gj 1 I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
-f Permit Issued to Registration Number
,-s� Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
',, R 3809 Main Street,Warrensburg,NY 12885
:. Name of Funeral Firm Making Disposition or to Whom
} ' Remains are Shipped, If Other than Above
;ems Address
it
1117.
Permission is hereby granted to dispose of the human remains described above as indicated.
A Date Issued Li 1 Z 1 1 7 Registrar of Vital Statistics W--A-A--stlArd—
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(signature)
:;:` District Number 56 0 ( Place C (Q/V-\S ca \ ' S/ v
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition 'lizi in Place of Disposition {?ntki,zw (mime o K_..
W (address)
CO
CY (section) ,,i (lot number) (grave number)
G Name of Sexton or Person in Charge of Premises / itr!5 ,Sii1Apr
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Z / (plea a print)
ILI Signature l .41 Title `RWA
(over)
DOH-1555 (02/2004)