Baker, Horace NEW YORK STATE DEPARTMENT OF HEALTH + --ff
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Horace Ormsb y Baker Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 1,2018 73 War or Dates n/a
i1 Place of Death Hospital, Institution or
Z City, Town or Village Bolton Landing,NY Street Address 833 New Vermont Road
DManner of Death LAiNatural Cause [Accident 0 Homicide E Suicide Undetermined n Pending
WICircumstances Investigation
w Medical Certifier Name Title
O Dr Smead,MD
Address
Bolton Landing,NY
Death Certificate Filed District Number Register Number
City, Town or Village Bolton Landing,NY
❑Burial Date Cemetery Crematory
❑Entombment February 5,2018 Pine View Crematory
Address
®Cremation Quaker Road,Queensbury,NY
Date Place Removed
Z Removal and/or Held
and/or Address
F_ Hold
N
O Date Point of
O.
❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address,
n Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY
Name of Funeral Firm Making Disposition or to Whom
l Remains are Shipped, If Other than Above
2 Address
ft
in
O. Permission is her by granted to dispose of the human remains •,-scri above as indicated.
Date Issued 2 2 zoi g Registrar of Vital Statistics )0$
(sign ure)
District Number (5_9 50 Place I Own oc )(D I4 On
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition Z J(o III Place of Disposition c,,A-_- 4w
Ili
(address
CO
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of Pre . es di% le „At
W lease print)
Signature Title IkM TVUL
(over)
DOH-1555(02/2004)