Alexander, Glyn NEW YORK STATE DEPARTMENT OF HEALTH .
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Glyn T. Alexander Male
Date of Death Age If Veteran of U.S. Armed Forces,
2/3/2015 48 _ War or Dates N/A
Place of Death Hospital, Institution or
City, Town or Village City of Johnsotnw Street Address 236 N. Perry Street
Manner of Death Natural Cause Accident Homicide Suicide Undetermined x Pending
4. Circumstances Investigation
•ti Medical Certifier Name Title
Margaret E.Luck Coroner
Address
:ti 223 West Main Street,Johnstown,NY 12095
....
Death Certificate Filed District Number Register Number
City, Town or Village City of Johnstown 1702 8
:::• ❑Burial Date Cemetery or Crematory
2/5/2015 Pine View Crematory
❑Entombment Address
• ®Cremation Queensbury, NY
: Date Place Removed
r Removal and/or Held
and/or Address
- Hold
-ti Date Point of
. Transportation Shipment
ti• by Common Destination
* Carrier
x
Disinterment Date Cemetery Address
•ti 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
:4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
?i• Permission is hereby granted to dispose of the human remains described ab ve as indicated.
x ---y4 Date Issued 2/4/2015 Registrar of Vital Statistics qo 1
..., (signature)
N. District Number Place
{ 1702 City of Johnstown,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
:, Date of Disposition 2/MS" Place of Disposition �,.,tVs.. Ceter r,,..,
,ti (address)
4-
x (section) (lot num ) (grave number)
.ti Name of Sexton or Person in Charge of Premises e imoor
,r please print)
•• Signature /.., • % Title C17/EVIf
(over)
DOH-1555 (02/2004)
A