Pereira, Joaquin e, -,1 290,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - ransit Permit
Name First Middle Last Sex
Joaquin Pereira Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 25,2016 86 War or Dates
Place of Death Hospital, Institution or
Z. City, Town or Village Glens Falls Street Address Glens Falls Hospital
.111
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Au Medical Certifier Name Title
a William Cleaver
Address
100 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Numb Register Number
[ ; City, Town or Village 6/
❑Burial Date Cemetery or Crematory
March 28,2016 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
E Hold
U)
0 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
►° Remains are Shipped, If Other than Above
Address
w
0` Permission is hereby granted to dispose of the human remains describ d ab ve in i a d.
Date Issued 03/22/zo/L Registrar of Vital Statistics / �
(signature)
'• District Number j 60/ Place '4�. AA` /U
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 31l il6 Place of Disposition gaUl.") Ceti
Ili
(address)
CO
Ce (section) N (lot number) (grave number)
pName of Sexton or Person in Char a of Premises It"� v rki,
'Z (Neese pint)
Signature _ C Z Title ( W4Yii--
(over)
DOH-1555 (02/2004)