Rodriguez Jonathan Miguel NEW YORKSTATE DEPARTMENT OF HEALTH -•- y Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jonathan Miguel Rodriguez Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/22/2020 39 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
p Manner of Death �Natural Cause 1:1Accident Homicide Suicide Undetermined Pending
U Circumstances Investigation
Uj Medical Certifier Name Title
Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 94
❑Burial Date Cemetery,Crematory or Facility Name
02/25/2020 Pine View Crematory
Entombment Address
aCremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
O
d Date Point of
(A 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
(... Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/25/2020 Registrar of Vital Statistics PpAert�7ndrewCartir(ElectmnwaY Signed)
(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:
f-
Z Date of Disposition 2 2 l,0 Place of Disposition
WOr+�
2 '(address)
W
N
� (section) �(lot number) (grave number)
a Name of Sexton or Person in Charge of Premises t°S
41
Z (ple a prin
W Signature Title 10'kyWKTpL
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 1 _3 3 7
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#