Holley, Jr. Jason IT
NEW YORK STATE DEPARTMENT OF HEALTH Z tic
Vital Records Section • Burial - Transit Permit
Name First Middle Last Sex
Jason H. Holley,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 9, 2011 87 War or Dates
Place of Death Hospital, Institution or
Z: City, Town or Village Saratoga Springs Street Address Saratoga Hospital & Nursing Home
d' Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W; Circumstances Investigation
w Medical Certifier Name Title
a. Edward M.Liebers Dr.
Address
3 Care Lane,Suite 300,Saratoga Springs,NY 12866
Death Certificate Filed District Number Register Ngber
City, Town or Village Saratoga Springs 4501 2 0
❑Burial Date Cemetery or Crematory
Entombment May 10,2011 Pine View Crematory
Address
Ex Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
yTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
a Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
t . Remains are Shipped, If Other than Above
t Address
CL
Ct Permission is hereby granted to dispose of the human remain cri d ab''ooe as indicate .
Date Issued CS' !l 0/2o t I Registrar of Vital Statistics -
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
wDate of Disposition C-'IL-t( Place of Disposition tee i w 6rv..q{privy,
2 (address)
LIJ
U)
O (section) 4 - L, (lot n�3''ber) (grave number)
p• Name of Sexton or Pers in Charge o Premises 1I'4' si-uprys id-
Z71t7L.
I (please print)
W
Signature Title (1/EMJ4i0
(over)
DOH-1555 (02/2004)
i