Andrews Jr., Russell ill # 31
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Russell E. Andrews,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 15,2018 61 War or Dates
8 Place of Death Hospital, Institution or
City, Town or Village Minerva Street Address 1502 County Route 29
ci Manner of Death Undetermined Pending
Cause Accident Homicide Suicide
Circumstances Investigation
w, Medical Certifier Name Title
0 Jennifer Donovan
Address
126 Ski Bowl Road,Johnsburg,NY 12843
Death Certificate Filed District Number Register Number c-
City, Town or Village Minerva 1557
❑Burial Date Cemetery or Crematory
Entombment October 17,2018 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
ZO I I Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N Transportation 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
IN-, Remains are Shipped, If Other than Above
• Address
CL
4.1 Permission is hereby granted to dispose of the huma emains described above as indicated.
Date Issued Jv- ►-1-Zo t g Registrar of Vital Statistics --V.--c--
(signature)
District Number 1557 Place T/O Minerva
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition I /i 'Ili Place of Disposition �;,u1L) r v4on�
(address)
W
Cl)
CL (section) number) ( 9 lumber)
p Name of Sexton or Person in Charge of PremisesZ aclot
tis/ SoM•►rt
W g4 (pl se print) —
Signature Title PIE Atr
(over)
DOH-1555 (02/2004)