Duckett, Walter William 86L
NEW YORKSTATE DEPARTMENT OF HEALTH r BUrIa� - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Wafter William Duckett Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/26/2019 91 Years War or Dates 1949-1962
�. Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Q Natural Cause Accident Homicide Suicide Undetermined Pending
W
U Circumstances Investigation
WQ Medical Certifier Name Title
Sean Bain MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 556
Burial Date Cemetery,Crematory or Facility Name
12/27/2019 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
OZ Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
a Date Point of
to ❑Transportation
p by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
inReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/27/2019 Registrar of Vital Statistics Wp6ertlndrewCunu(E&tmnrcalySi,=4
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
wDate of Disposition I��q Place of Disposition t
2 ess)
W
(section) (lot number) (grave number)
OName of Sexton or Person in Charge of Prem'
z (please print)
W Signature Title c t"
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) E 31,95
Receipt
Human remains of delivered on + , 20
Pine View Cemetery Representing the f6etal.h6me named on burial permit
Official Funeral Directors Reg.or License# —