Remington, John Roscoe NEW YORKSTATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Per 1`1
Name First Middle Last Sex
John Roscoe Remington Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/11/2020 83 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Horicon Town Street Address 153 Pease Hill Road, Horicon Town, New York 12815
lu
p Manner of Death Natural Cause Accident Homicide ❑Suicide Undetermined Pending
VCircumstances Investigation
LU Medical Certifier Name Title
Bryan Smead MD
Address
3767 Main Street,Warrensburg Town,New York 12885
Death Certificate Filed District Number Register Number
City,Town or Village Brant Lake 5654 4
❑Burial Date Cemetery,Crematory or Facility Name
02/18/2020 Pine View Crematory
Entombment Address
r7Cremation Queensbury Town,New York
❑Donation
0 ❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
d. Date Point of
N ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
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
II— Remains are Shipped,If Other than Above
Address
W
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/18/2020 Registrar of Vital Statistics xrzrtaG Wbod(EfertronkaldySy wd)
(signature)
District Number 5654 Place Brant Lake, 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 1`) l0 Place of Disposition < rw—
LU /address/
W
N
M (section) (lot number) (grave number)
A
93 Name of Sexton or Person in Charge of Premises r�d �it
Z 01 ase print)
W Signature Title
DO H-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 110113
Receipt
Human remains of delivered on , 20
f.
0
Pine View Cemetery Representing the funeral home named,on burial permit
Official Funeral Directors Reg.or License#