Baptiste-Corriveau, Jacksene NEW YORK STATE DEPARTMENT OF HEALTH ' - .-w I 'I`'
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jacksene Jean Baptiste-Corriveau Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 13,2016 15 War or Dates
.. Place of Death Hospital, Institution or
City, Town or Village Warrensburg Street Address 148 Moose Ridge Drive
Manner of Death Natural Cause Accident Homicide X Suicide Undetermined Pending
tri Circumstances Investigation
m; Medical Certifier Name Title
0 Michael Sikirica
Address
50 Broad St.,Waterford,NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village Warrensburg 5660
❑Burial Date Cemetery or Crematory
❑ January 19,2016 Pine View Crematory
Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
O.
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
b Remains are Shipped, If Other than Above
', . Address
mit
Permission is he eby ranted to dispose of the human remains descri d above as indicated.
Date Issued lS Registrar of Vital Statistics — G`''`____-1
(signature)
District Number 5660 Place Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date
of Disposition (/Zc hi, Place of Disposition s, V.... (r.wn,ar(or+u•.
(address)
IIJ
U)
Ce (section) /71(lot number) (' (grave number)
p [Name of Sexton or Person in Charg of Premises f;sf04,— vi/ '
`LI
Z //, (please print)
Signature G-"� { Title l)"LdAlftZ(
(over)
DOH-1555 (02/2004)