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Cleveland, Andrew
).C171 NEW YORK STATE DEPARTMENT OF HEALTH - ..Vital Records Section Burial - Transit Permit Name First Middle Last Sex Andrew J.H. Cleveland Male Date of Death Age ` If Veteran of U.S. Armed Forces, July 20,2018 38 War or Dates Place of Death Hospital, Institution or Z: City, Town or Village Johnsburg Street Address S. Johnsburg Road aManner of Death I I Natural Cause X Accident I I Homicide Suicide Undetermined Pending Lit Circumstances Investigation lwif Medical Certifier Name Title el Michael Sikirica Address 50 Broad St.,Waterford,NY 12188 Death Certificate Filed District Number Register Number City, Town or Village 17 ❑Burial Date Cemetery or Crematory ❑Entombment July 23,2018 , Pine View Crematory Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z I I Removal and/or Held and/or Address F' Hold CO I O Date I Point of NTransportation Shipment p by Common Destination Carrier 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 Street, Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom t-. Remains are Shipped, If Other than Above 2 Address rt 0` Permission is her by gr nted to dispose of the human remain es ri ed above as indicat . Date Issued q Registrar of Vital Statistics �r ,-C- O _� (signature) District Number & Place ---ro o Q t vt_S ( �j I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition %/,t 4/1 jr Place of Disposition pi fs, U t,t,' c,r.c c,4 00` W (address) Cl) fY (section) (lot number) (grave number) Q Name of Sexton or Person in Charge of Premises e,Cp`{'Y S?.,N.nifLS Z (please print) W Signature , " 4,;,.._,-./ C�Title re.ria.4a t i (over) DOH-1555 (02/2004)