LorrainJr. Wilfred Charles . & /Is"
NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Wilfred Charles Lorrain Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/04/2020 78 Years War or Dates 1960-1964
H Place of Death Hospital,Institution or
WCity,Town orViltage Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
U Title
W Medical Certifier Name
13 Michael Miles MD
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town orVilla a Queensbury 5657 38
Burial Date Cemetery,Crematory or Facility Name
03/05/2020 Pine View Crematory
Entombment Address
QCremation Queensbury Town,New York
Donation
Z Date Place Removed
0 ❑Removal and/or and/or Held
�
N
Hold Address
IL Date Point of
W ❑Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
JE] Date Cemetery Address
Reinterment
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 orto Whom
F. 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 03/05/2020 Registrar of Vital Statistics CarnCrneXrGlegarde Bar6er(Ekctronr �ca Srgned�
(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:
H
W Date of Disposition 3 Zo Place of Disposition (address/
2
W
(section) (iotnumber/ (grave number/
Name of Sexton or Person in Charge of Premises (Pase P, f J ri0ot)
Signature Title
DO H-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) ` -
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#