Green, Arnold NEW YORK STATE DEPARTMENT OF HEALTH t11L
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Arnold • Isaac Green Male
Date of Death Age , If Veteran of U.S. Armed Forces,
0Q12v121111_ 86 years War or Dates w w I I
f•- Place of Death Hospital, Institution or
City, Towg /lil �XX Glens Falls ` Street Address CIPns Falls Hnspital
Manner of Death❑Natural Cause 0 Accident Homicide p Suicide Undetermined 0 Pending
W Circumstances Investigation
at Medical Certifier Name Title
0 Sean Bain M f)
Address
100 Park St. Glens Falls, N Y .
Death Certificate Filed District Number Register Number
City, TowRiekiMtilitxX nIPns Falls 5601 424 .
❑Burial Date Cemetery or Crematory
❑Entombment 0 /2 93/2011 Pine View Cemetery
Address
❑C,emation Queensbury. NY 12804
ZDate Place Removed
❑Removal and/or Held
2 and/or Address
N Hold
0 itDate Point of
❑Transportation Shipment
0 by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom .
.1. . Remains are Shipped, If Other than Above
Address
U
9!. Permission is hereby granted to dispose of the human remains descri ed abov s in a d.
Date Issued 09/23/2011 Registrar of Vital Statistics 40/ ��
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition 't11lIl Place of Disposition PINVW., C �(wt-
tii
(address)
0
CC g (section) (lot numb") (grave number)
Ca Name of Sexton or Person in Charge o Premises Art's\ .. .ogli-
Z
(please print)
41. Signature A Title COgikRi
(over)
DOH-1555 (02/2004)