Bakerian, Keith NEW YORK STATE DEPARTMENT OF HEALTHT Burial - Transit Per/f3.
Vital Records Section it
Name First Middlio Last Sex
Keith E. Bakerian Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. February 2, 2018 57 War or Dates
z Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Residence
0 Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined n Pending
W Circumstances Investigation
O Medical Certifier Name Title
W Michael Sikirica MD
d Address
50 Broad Street, Waterford, NY 12188
Death Certificate Filed District Number 67a, Register Number 3
City,Town or Village Whitehall
❑Burial Date Cemetery or Crematory
February 9, 2018 Pineview Crematorium
❑Entombment Address
a, CI Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
4 n Removal and/or Held
and/or Address
1" Hold
0 Date Point of
0 ❑Transportation Shipment
L by Common Destination
Carrier
- Date Cemetery Address
a ❑Disinterment
❑ Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
W Address
O.
Permission is hereby granted to dispose of the human r 7 ins described above as indica ed.
Date Issued a 11 10.0 i Registrar of Vital Statistics a-
(signature)
District Number 57 a 2 Place Whitehall,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 02/09/2018 Place of Disposition Pineview Crematorium
W (address)
0
It
0 (section) lot number) (grave number)
O Name of Sexton or Person in Charge of Premi es (Arsi ,r Ss-.dl
Z (pl se print)
W
Signature Title aZ>rlhMg_
(over)
DOH-1555 (02/2004)