Jordon Jr.,William Oliver # %Z()
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
William Oliver Jordan Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/08/2019 56 Years War or Dates
Place of Death Hospital,Institution or
~ ,Town or Village Albany Street Address Albany Medical Center Hospital
W City,
p Manner of Death 0 Natural Cause Accident Homicide 1:1Suicide Undetermined Pending
W Circumstances Investigation
V
W Medical Certifier Name Title
Sean Geary MD
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed District Number Register Number
City,Town or Village Albany 0101 2668
Burial Date Cemetery,Crematory or Facility Name
12/09/2019 Pine View Crematory
Entombment Address
iCremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
dDate Point of
N Transportation Shipment
by Common
Carrier Destination
Disinterment
Date Cemetery Address
1EIReinterment
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
Lu
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/09/2019 Registrar of Vital Statistics rDanfe&s'(�'iQespre(ElectronrcaffySrgned�
(signature/
District Number 0101 Place Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition fZ 117,1 IS Place of Disposition �v •✓t
W (address)
t!J ravenumber)
U) (section) lot number/ (g
Name of Sexton or Person in Charge of Premises (ie ep orl t) �l
W Signature Lam' �- Title ��
DO H-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) " 1 14 6
Receipt
Human remains of delivered on , 20 s
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#�'- '
i
i