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Williams Sr, John L.
H sot NEWYORK STATE DEPARTMENT OF HEALTH "• - Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John L.Williams Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 05/03/2020 72 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital 'p Manner of Death © Natural Cause 1:1Accident Homicide Suicide ❑Undetermined Pending Circumstances Investigation W Medical Certifier Name Title C3 Scott Biasetti MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 197 Burial Date Cemetery,Crematory or Facility Name 05/05/2020 Pine View Crematory Entombment Address Cremation Queensbury Town,New York Donation OZ Removal Date Place Removed and/or and/or Held ~ Hold Address N O n. Date Point of to ❑Transportation Q by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above Address W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/04/2020 Registrar of Vital Statistics `IZ9bert 4ndirew Curtis(ECectronicalTy 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: Is 1 P Z Date of Disposition S Z� Place of Disposition �u�✓ fc�—% LU (address) W N (section) (totnumber/ (grave number) M - a Name of Sexton or Person in Charge of Premises ^ A'W(k (p/ se print/ W Title A'h,AiA Signature Z/ Z4 DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Y+ 013 Receipt Human remains of delivered on , 20 Pine View Cemetery Represehrildg the funeral/home named on burial permit Official Funeral Directors Reg.or License#