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Cook, Jay 4 I h' 1 CO NEW YORK STATE DEPARTMENT OF H Vital Records Section Burial - Transit Permit I r Name First Middle Last Sex 3 Jay Ernest Cook Male Date of Death Age '" f Veteran of U.S.Armed Forces, .... 10/02/2018 62 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls `s Street Address Glens FallsHospital Manner of Death©Natural Cause Accident Ej Homkide 0 Suicide II Undetermined �Pending -;> Circumstances Investigation Medical Certifier Name Title Marciile Labban MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number u City, Town or Village Glens Falls r 5601 473 0 Burial Date "' Cemetery or Ciatory ## 10/03/2018 Pine View Crematory Entombment Address ®Cremation Queensbury Town, New fork Date Place Removed a Removal and/or Held and/or Address • Hold Date Point of • 0 Transportation Shipment ,, by Common Destination Y Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 g Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/03/2018 Registrar of Vital Statistics cRp6ertA Curtis(Electronicai y Signed) (signature) District Number 5601 Place Glens Falls, New York 3F 77 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition I6 11111 Place of Disposition Pat, 4.1 art, (address) (section) (lot numb') (grave number) • Name of Sexton or Person in Charge of Premises / l"'�y",-_)r"^lit (please print) Signature 4'k7 Title 46 rill filt, (over) DOH-1555 (02/2004)