Senical, Gary Edward NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Gary Edward Senical Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/30/2020 67 Years War or Dates
II.- Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
0 Shahid Ahmed MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 55
❑Burial Date Cemetery,Crematory or Facility Name
02/03/2020 Pine View Crematory
Entombment Address
517 Cremation Queensbury Town,New York
Donation
� �Removal Date Place Removed
and/or and/or Held
~ Hold Address
U9
a Date Point of
N Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
JE]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
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/03/2020 Registrar of Vital Statistics Wp6ert�lrrdmwCurt&(Electrvnzcaffystgrted)
(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:
Z Date of Disposition Z f Lj Place of Disposition Yv
LL! (address)
2
W
N (section) (lot number) (grave number)
Q
Name of Sexton or Person in Charge of Pre ' es (P
(p!e print
W Signature Title
DO H-1555(o7/18)p 1 of 2
i
Public Health Law Sec. 4145(2b) 013 3(. 7
i
Receipt
i
Human remains of i delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#