Coers, Jack NEW YORK STATE DEPARTMENT OF HEALTH G IN # v 1)
Vital Records Section Burial - Transit Permit
k Name First Middle Last Sex
Jack Warren Coers Male
E.__ Date of Death Age If Veteran of U.S. Armed Forces,
c 07/13/2018 81 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death Natural Cause 0 Accident Ej Homicide 0 Suicide ri Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Wendy Steinhacker PA
Ya
Address
100 Park St,Glens Falls,New York 12801
41,
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 344
iti❑Burial Date Cemetery or Crematory
07/16/2018 Pine View Crematory
❑Entombment Address
ECremation Queensbury Town, New York
takl
Date Place Removed
Removal
• and/or and/or Held
Address
Hold
Date Point of
Transportation Shipment
I• . by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment0,1
wo DI Date Cemetery Address
iti
Permit Issued to Registration Number
4. Name of Funeral Home Maynard D Baker Funeral Home 01130
pi 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
tiii P• ermission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued 07/16/2018 Registrar of Vital Statistics Rp6ertA Curtis(Efectronicafy Signed)
(signature)
District Number 5601 Place Glens Falls, New York
tel
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
" D• ate of Disposition 7 lig l i g Place of Disposition e..t1,,. (12/1.17r"`_
12,
(address)
(section) A(lot n p mb (grave number)
t -_
• N• ame of Sexton or Person in Charge of Premises r„ L f,,.tif-
(pl se print)
ni Signature *Alt if !"8
✓i--
(over)
DOH-1555 (02/2004)