Russell Jr, Bernard NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Bernard H. Russell,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 5,2015 64 ' War or Dates
: Place of Death Hospital, Institution or
Z City, Town or Village Warrensburg Street Address 22 Oak Street
8, Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
l Circumstances Investigation
_tu Medical Certifier Name Title
0 Bryan Smead MI)
Address
Bolton Health Center,Bolton Landing,NY 12814
Death Certificate Filed District Number Register Number/6
City, Town or Village T/O Warrensburg 5660
❑Burial Date Cemetery or Crematory
September 9,2015 Pine View Crematory
E Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
N Hold
O Date Point of
N Transportation Shipment _
p by Common Destination
Carrier
Disinterment Date Cemetery Addres'
Reinterment Date Cemetery Addre
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
▪ Remains are Shipped, If Other than Above
• Address
Iii
0° Permission is hereby granted to dispose of the human ' s escribed above as indicated.
Date Issued 09/08/2015 Registrar of Vital Statisti s
(signature)
District Number 5660 Place T/O Warrensburg,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition qAqlis' Place of Disposition Pi,.'tJ. tcr,dr.,,
E (address)
W
U)
tY (section) A (lot number), (grave number)
pName of Sexton or Person in Charge of Premises lhTr .. .51,04-
`Z �Iplease print)`
Signature L it�r- Title /R ea
l� (over)
DOH-1555 (02/2004)