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Maynes, James i zZ© NEW YORK STATE DEPARTMENT OF HEALTH Burial G Transit Permit Vital Records Section Burial Name First Middle Last �� / , ( Sex }'- Date of Death • Age f If Veteran of U.S.Armed Forces. 13 } �' - ; War or Dates jgSSS'- I(4Q.- I Place fi Death s Hospital, Institution or ZCo A-vi ofi o- ?..e,i City. ow or Village v Street Address 0U�-Pnchxr� t\JV f1= p Manner of Death ► Natural Cause © ident [l Homicide 0Suicide Q Undetermindd (' Pending l� Circumstances investigation uri Medical Certifier Name Pa I-r-,' cI a. ,f?cven 5a i) Title p/6/- - Address /4/ Lc -et( /Id aye epS6v A! --/ J' Y / o Death Certificate Filed 1 District Numbet 1 Register Number Cite, c r Village (�Qe p r u b U i S Lie ru i 3 l .- D6uriai Date Cemetery or Crematory . 3► ► � 1 'per v1{ui C lenia . [I Eftar+)oment i Address •: 2C,ema ion OuaLtx 12vr, r�1 I.),� s bLi,-j t r ' I z,'°y Date Place Removed l Removal _ 1 �i and/or Held a 7i'.�Or Address Hold th ei ( Date Point of . 131ET an p©rtation i Shipment 01 Common I Destination Carrier r.: i Date ► CemeteryAddress LI Disinterment :•�� b Date I Cemetery Address . C I Re:nterrnir:nt �' Perm Issued t© '_ ; Registration Number Name of Funeral Home.. . Baker Funeral Home 1 01130 { Address 11 Lafayette St., Queensbury, NY 12804 Na>>> ofFuneral Firm Malting Disposition or to Whom 1—" Rem ins are Shipped, If Other than Above • , Address ,E . 1 Per rn isssion is hereby arentted t dispose of the human remains described above es indicated. :...: • Date issued S- ill-- ap{ g- _ Registrar of Vital Statistics �(,�•L. Q r�y+U (signature) District Number St C 1 Place .(DoeenS bvrt� 1_1 I cat iiiy that the remains of the decedent identified above were disposed of in accordance with this permit on: Mi Da Disposition 31 is-III Place of Disposition gat.. 4•-c`le-.., (address) WI MI (section) number) (grave number) �i Name of Sexton or Person in Charge f Premises (riot,. M( (pl se print) 1 Signature /r'� Title • _ (over) DOH-1555 (02/2004)