Baroudi, Jeffrey NEW YORK STATE DEPARTMENT OF HEALTH * I Burial Records Section Burial - Transit Permit
Name First Middle Last Sex
Jeffrey A. Baroudi Male
u Date of Death Age If Veteran of U.S. Armed Forces,
December 9,2017 66 War or Dates
Place of Death Hospital, Institution or
{
City, Town or Village Bolton Street Address 354 Potter Hill Road
Manner of Death Undetermined Pending
X Natural Cause Accident Homicide Suicide
E1 Circumstances Investigation
Medical Certifier Name Title
John Stoutenberg MD
Address
102 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Bolton 5650 43
❑Burial Date Cemetery or Crematory
Entombment December 15,2017 Pine View Crematory
Address
Ei Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
5 2and/or Address
H Hold
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0 Date Point of
cnTransportation Shipment
p by Common Destination
Carrier
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 Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I!* Remains are Shipped, If Other than Above
Address
1e
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I of•13• ) 1 Registrar of Vital Statistics -PA ZCIL L e /sy\
(signature)
District Number 5650 Place Bolton
i•- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition I=t ii In Place of Disposition f'.1t0 -, (4,,,c;,iur='-'-^
W (address)
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C4 (section) number) (grave number)
Z Name of Sexton or Person in Charge of Premises 4.(1.ot
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Z ,l� (please print)
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Signature (.�( %le Title trikie 1 tU,2
(over)
DOH-1555 (02/2004)