Ordway, Jay NEW YORK STATE DEPARTMENT OF HEALTH # 11
Vital Records Section t - # Burial - Transit Permit
Name First Middle Last Sex
Jay W. Ordway Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 6,2011 73 War or Dates 1956- 1960
Place of Death Hospital, Institution or
E City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death n Natural Cause Accident Homicide Suicide Undetermined Pending
w Circumstances Investigation
tki Medical Certifier Name Title
"0 Mark M.Hoffman
Address
420 Glen Street,Glens Falls,NY 12801
k y Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 1 b3
❑Burial Date Cemetery or Crematory
April 11,2011 Pine View Crematory
Address
0 Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
F_ Hold
N
O 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 00035
Address
• 3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
M Remains are Shipped, If Other than Above
Address
4'
131:
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I &" ) Registrar of Vital Statistics 1...�c - v�
(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:
Z
W Date of Disposition 4+IZ-I( Place of Disposition ►uUi;u.) C,iow.<tur,v4._
W (address)
co
tY (section) (lot nurr) (grave number)
pName of Sexton or Per n in Charge Premises l�r,1}d,�Yr Jt olt-1 f'i—
Z / L li (please print)
W Signature L 'plc_ Title �Q�Mi-
f
(over)
DOH-1555 (02/2004)