Ireland, Trevor r \ at3 D
NEW YORK STATE DEPARTMENT OF HEALTH Burial - ransit Permit
Vital Records Section
:' Name First Middle Last Sex
. Trevor Winslow Ireland Male
• ° Date of Death Age If Veteran of U.S. Armed Forces,
January 5,2016 26 War or Dates N/A
• Place of Death Hospital, Institution or
Z City, Town or Village Town of Canastota Street Address 238 Genesee Street Apt C
0 Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide x
Circumstances Investigation
W Medical Certifier Name Title
Kenneth Clark MD
Address
100 Elizabeth Blackwell Street Syracuse,NY 132 10
Death Certificate Filed District Number Register Number
,.
• City, Town or Village Madison County 0 lJ
❑Burial Date Cemetery or Crematory
[�Entombment January 11, 2016 Pine View Crematory
Address
RI Cremation Queensbury,NY
Date Place Removed
Z Removal and/or Held
2 and/or Address
H Hold
N
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
x Name of Funeral Home Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
tr
W
Permission is hereby granted to dispose of the human re ins descri d above as indicated.
Date Issued J— --/6 Registrar of Vital Statistics ✓,_ l
(signature)
• District Number Place tk
H
I certify that the remains of the decedent identified above were dispo d f in accordance with this permit on:
w Date of Disposition 6/I3 (iL Place of Disposition el fin, �, �..
E (address)
W
U)
Ce (section) / Jiot nu er) (grave number)
ap Name of Sexton or Person in Charge of Premises Ir.s
IZ please print)
Signaturefi Title 0?Fc1- .
(over)
DOH-1555 (02/2004)