Evans,Gary Lee (2) NEW YORKSTATE DEPARTMENT OF HEALTH F . t S1
Bureau of Vital Records Burial Transit Permit
Name First Middle Last Sex
Gary Lee Evans Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/15/2020 72 Years War or Dates
II.— Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town —7Street Address Warren Center for Rehabilitation and Nursing
W Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide g
Circumstances Investigation
C.)
W Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 8
❑Burial Date Cemetery,Crematory or Facility Name
01/16/2020 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
H Hold Address
O
d Date Point of
to �Transportation p by Common Shipment
Carrier Destination
❑Disinterment Date Cemetery Address
11 Reinterment 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
Q
W
[' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/16/2020 Registrar of Vita[Statistics Caroline-W4-0yarde Bar&r(EYectronwadySy"4
(signature)
District Number 5657 Place Queensbury, 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 11 `iQ Place of Disposition ha v
W (address)
2
W
N (section) lot number) (grave number/Ir drij
gy Name of Sexton or Person in Charge of Premises
Z /z9v (pl print)
W Signature Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013251
Receipt
0
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ` --