West Sr, William 1 # , i
NEW YORK STATE DEPARTMENT OF HEALTH r t
Vital Records Section Burial - Transit Permit
= 7i Name First Middle Last Sex
William H. West,Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 17,2016 75 War or Dates Vietnam 1
N Place of Death Hospital, Institution or
: ` City, Town or Village Glens Falls Street Address Glens Falls Hospital
., Manner of Death X Natural Cause i I Accident I !Homicide -I Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
a
Y: Address
. !: Death Certificate Filed District Number Regir Number
° = City, Town or Village g
��, Y 9 Glens Falls 5601
❑Burial Date Cemetery or Crematory
January 19,2016 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
O and/or Address
—I— Hold
Cl)
O Date Point of
N I I Transportation Shipment
p by Common Destination
_ Carrier
Date Cemetery Address
I. I Disinterment
I I Reinterment
Date Cemetery Address
a ;I: Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
51 Address
°°_4: 3809 Main Street,Warrensburg,NY 12885
m>a; 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 )/19) 1, Registrar of Vital Statistics U\-) CA LA)
r -' ' (signatur
A District Number 5 t ( Place 6 (itv S F A VI. S N Li
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 1 /70//t Place of Disposition &,j&.../ C rixp....-
w (address)
CO
r4
(section) (lot number) S (grave number)
p Name of Sexton or Person in Char of Premises n,t ,,. Ln t
Z (p se print)
W Signature G•, rc Title CEIMi 11,Q
(over)
DOH-1555 (02/2004)