Baker, Samuel NEW YORK STATE DEPARTMENT OF HEALTH'S
Vital Records Section Burial - Transit Permit
., Name First Middle Last Sex
Samuel Anthony Baker Male
- Date of Death Age If Veteran of U.S. Armed Forces,
r . August 8,2015 74 War or Dates 1963 - 1965
, Place of Death Hospital, Institution or
Z. City, Town or Village Horicon Street Address 66 Davis Road
' Manner of Death —Undetermined Pending
IAA X Natural Cause Accident Homicide Suicide
Ili Circumstances Investigation
a Medical Certifier Name Title
4:4,' Ageel Gillani MD
Address
CR Wood Cancer Center, 102 Park St.,Glens Falls,NY 12801
' Death Certificate Filed District Number Register Number
.x City, Town or Village 5654 3
III Burial Date Cemetery or Crematory
August 12,2015 Pine View Crematory
❑Entombment Address
0 Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F- Hold
N
Q Date Point of
N ' I Transportation Shipment
`a 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
Remains are Shipped, If Other than Above
°
Address
X
W
Permission is hereby granted to dispose of the human remain described ab as ' dicate/
,�;- Date Issued )(-/1 Registrar of Vital Statistics G. -1
(signature)
District Number 6464 Place T/O Horicon,NY
I certify that the remains of the decedent identified above were disposed off in accordance with this permit on:
W Date of Disposition '(i3jt S" Place of Disposition eft L, 64V. to r...mo
2 (address)
W
co
C (section) C4 (lot numb (grave number)
pName of Sexton or Person in Charge of Premises r.► tom_
W / (please print)
Signature Title ( h1?
(over)
DOH-1555 (02/2004)