VanAken, PaulNEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
t 6K(
LF Burial - Transit Permit
Name First Middle Last
Sex
Paul Rohde Van Aken
Male
Date of Death
Age
If Veteran of U.S. Armed Forces,
09/28/2019
72 Years
War or Dates 1967-1989
Place of Death
Hospital, Institution or
W
City, Town or Village Glens Falls
Street Address The Pines At Glens Falls Center For Nursing & Rehabilitation
p
Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
W
Circumstances Investigation
U
W
Medical Certifier Name Title
Gwendolyn Morris -Dickinson PA
Address
170 Warren St, Glens Falls, New York 12801
Death Certificate Filed
District Number
Register Number
City, Town or Village Glens Falls
5601
424
Burial
Date
Cemetery, Crematory or Facility Name
10/01/2019
Pine View Crematory
Entombment
Address
x❑ Cremation
Queensbury Town, New York
Donation
Removal
Date
Place Removed
0
and/or Held
and/or
�
Address
FA
dDate
Point of
(A
DTransportation Shipment
p
by Common
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
F.
Remains are Shipped, If Otherthan Above
Address
cr
W
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/01/2019 Registrar of Vital Statistics 2o6ettgndrew Curtis (EkctronicaffySoneQJ
(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: `
H
Z
Date of Disposition �f, Z 1 Place of Disposition ` (tJrr—
uJ
(address)
2
W
to
(section/ (lot number/ (grave number)
0
Name of Sexton or Person in Charge of Premises (pl seprint/
Z
W
Signature Title
Public Health Law Sec. 4145(2b)
012574
Receipt
Human remains of
Pine View Cemetery
Official
delivered on 20
Representing the funeral home named on burial permit
Funeral Directors Reg. or License # i ' I , t!`;