Baker Jr., Richard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard Joseph Baker Jr Male
. Date of Death Age If Veteran of U.S. Armed Forces,
, 01/17/2018 92 Years War or Dates 1944-1945
Place of Death Hospital, Institution or
i City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
Manner of Death gi Natural Cause ❑;'kccident ❑Homicide ❑Suicide ❑Undetermined Fi❑Pending
Circumstances Investigation
la Medical Certifier Name Title
1 Gwendolyn Morris-Dickinson PA
Address
F.^ 170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 30
: ❑Burial Date Cemetery or Crematory
01/18/2018 Pine View Crematory
;`❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
g ri❑and/or Removal and/or Held
;; Address
.i. Hold
EDate Point of
❑Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
,:!❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
'` Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
Frr 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 01/18/2018 Registrar of Vital Statistics 12o6ertA Curtis(E(ectronica((ySigned)
(signature)
District Number 5601 Place Glens Falls, New York
. t I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /-/9-/g Place of Disposition f�1 Q-V r ei„,"-G ,i-ei,y
1 (address) /
tn
llt (section) 1 (lot number) (grave number)
Name of Sexton or y-r ' Charge of Premises J w/r G4-1 64-ro-1 G it£
Z+, (please print)
t Signature —./(4.. �" Title ere_ wTa(---
(over)
DOH-1555 (02/2004)