Baker, Glenwood NEW YORK STATE DEPARTMENT OF HEALTH ► fr 41
Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
A Glenwood L. Baker Male
It Date of Death Age If Veteran of U.S. Armed Forces,
June 11, 2016 95 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier me a Title
trt" 1Z-ecJ %, —Dr .
Address
1OUpark_ s -r 1 scells , IN /2 -b
g�th Certificate Filed District Number Register Number
51-54
it y own or Village Glens Falls 5 /,c: ( q
❑Burial Date Cemetery or Crematory
June 13, 2016 Pine View Crematory
'❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
0 Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
4
44
❑ Disinterment Date Cemetery Address
IllReinterment Date Cemetery Address
K
�ry
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ,!;3 /1 b Registrar of Vital Statistics L joc).A.A.
t (signs life)
y, District Number .5&I Place e (DA^S VcU\\s ).)
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06/13/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
: Name of Sexton or Person in Charge of remises &Ill-- Jt.,
r ® (please print)
Signature 11 Title CMe}Tit_
(over)
DOH-1555 (02/2004)