Gardinier, JohnA 6tt
N EW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
Burial - Transit Permit
Name First Middle Last
Sex
John Elmer Gardinier
Male
Date of Death
Age
If Veteran of U.S. Armed Forces,
09/15/2019
81 Years
War or Dates
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Place of Death
Hospital, Institution or
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City, Town or Village Elizabethtown Town
Street Address Elizabethtown Community Hospital
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Manner of Death ❑X Natural Cause 1:1Accident Homicide ❑ Suicide Undetermined Pending
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Circumstances Investigation
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Medical Certifier Name Title
Mary Halloran MD
Address
75 Park Street PO Box 277, Elizabethtown Town, New York 12932
Death Certificate Filed
District Number
Register Number
City, Town or Village Elizabethtown
1552
53
❑ Burial
Date Cemetery, Crematory or Facility Name
Entombment
09/18/2019 Pine View Crematory
Address
X❑ Cremation
Queensbury Town, New York
Donation
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Removal
Date
Place Removed
and/or
and/or Held
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Hold
Address
N
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d
Date
Point of
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❑ Transportation
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
Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/17/2019 Registrar of Vital Statistics ,%anetECross (E&tronica,( Soned�
(signature)
District Number 1552 Place Elizabethtown, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition Place of Disposition ,,. .j �r f a•�.i
(address)
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N
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(section) Aot number/ (grave number)
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of Sexton or Person in Charge of Premises �t �""�
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Signature � ^.t'�— Title
DO H-1555 (07/18) p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of J
Pine View Cemetery
Official
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012542
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Repres g the ral home named o�p al permit
Funeral Directors Reg. or License # ` `��'
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