Baker, George Ernest NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
George Ernest Baker Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/12/2020 77 Years War or Dates
�. Place of Death Hospital,Institution or
Z City,'Town or Village Thurman Town Street Address 254 Mountain Road,Thurman Town, New York 12810
j Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined ❑Pending
Uj C.) Circumstances Investigation
WD Medical Certifier Name Title
Paul Bachman MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Athol 5659 0001
171 Burial Date Cemetery,Crematory or Facility Name
02/19/2020 Pine View Crematory
Entombment Address
Cremation Queeiis15ury, New York
Donation
ZO Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
(L Date Point of
N n Transportation
p by Common Shipment
Carrier Destination
El Disinterment
Date Cemetery Address
In 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
H. Remains are Shipped,if Other than Above
Address
IM
W
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/19/2020 Registrar of Vital Statistics SusanStapks(ik--tronk-affySigned�
(signature)
District Number 5659 Place Athol, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition 2/70 i 1 O Place of Disposition
W
LU (address)
W
N
M (section) (lot number) (grave number)
a Name of Sexton or Person in Charge of Premises r'j L Mit
5—
Z / aseprint/
W Signature ✓J „� Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 01,3 -0 2
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#